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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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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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Bhat M, Malm T, Sjöberg G, Nordenstam F, Hanséus K, Rosenkvist CJ, Liuba P. Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair. Front Cardiovasc Med 2024; 11:1349166. [PMID: 38606378 PMCID: PMC11007042 DOI: 10.3389/fcvm.2024.1349166] [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] [Received: 12/04/2023] [Accepted: 03/18/2024] [Indexed: 04/13/2024] Open
Abstract
Background ECG abnormalities have been linked to adverse changes in right ventricular (RV) morphology and poor clinical outcomes in repaired Tetralogy of Fallot (rTOF). Our aim was to describe how ECG changes progress in early and intermediate follow-up and whether types of surgical strategy at the time of primary repair affected these changes. Methods We studied patients with rTOF born 2000-2018 operated at our institution. Seven time points in relation to primary repair, follow-up, and pulmonary valve replacement (PVR) were identified. Patients correct with valve sparing repair (VSR), trans-annular patch (TAP) including with a monocusp valve (TAP + M) and with at least 3 ECGs were included. PQ interval, QRS duration, dispersion, and fragmentation, QTc duration and dispersion, JTc as well as presence of a right bundle branch block (RBBB) were analyzed. Medical records were reviewed for demographic and surgical data. Results Two hundred nineteen patients with 882 ECGs were analyzed with a median follow-up time of 12.3 years (8.4, 17) with 41 (19%) needing PVR during the study period. QRS duration increased at time of primary repair to discharge from 66 msec (IQR 12) to 129 msec (IQR 27) (p < 0.0001) and at 1- and 6- year follow-up but showed only a modest and temporary decrease after PVR. QTc increased at the time of primary repair as well as prior to PVR. PQ interval showed a small increase at the time of primary repair, was at its highest prior to PVR and decreased with PVR. Type of surgical repair affected mainly QTc and JTc and was consistently longer in the TAP + M group until PVR. In VSR, QTc and JTc were prolonged initially compared to TAP but were similar after 1 year. After PVR, there were no differences in adverse ECG changes between surgical groups. Conclusions PQ interval and QRS duration best correspond to the assumed volume load whereas the relationship with QTc and JTc is more complex, suggesting that these represent more complex remodeling of the myocardium. Before PVR, QTc and JTc are longer in the TAP + M group which may be due to a longer surgical incision.
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Affiliation(s)
- Misha Bhat
- Department of Pediatric Cardiology, Pediatric Heart Center, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Torsten Malm
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatric Cardiac Surgery, Pediatric Heart Center, Skane University Hospital, Lund, Sweden
| | - Gunnar Sjöberg
- Department of Pediatric Cardiology, Department of Women’s and Children’s Health Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Felicia Nordenstam
- Department of Pediatric Cardiology, Department of Women’s and Children’s Health Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Katarina Hanséus
- Department of Pediatric Cardiology, Pediatric Heart Center, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | - Petru Liuba
- Department of Pediatric Cardiology, Pediatric Heart Center, Skane University Hospital, Lund, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Avesani M, Jalal Z, Friedberg MK, Villemain O, Venet M, Di Salvo G, Thambo JB, Iriart X. Adverse remodelling in tetralogy of Fallot: From risk factors to imaging analysis and future perspectives. Hellenic J Cardiol 2024; 75:48-59. [PMID: 37495104 DOI: 10.1016/j.hjc.2023.07.008] [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: 02/20/2023] [Revised: 05/29/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023] Open
Abstract
Although contemporary outcomes of initial surgical repair of tetralogy of Fallot (TOF) are excellent, the survival of adult patients remains significantly lower than that of the normal population due to the high incidence of heart failure, ventricular arrhythmias, and sudden cardiac death. The underlying mechanisms are only partially understood but involve an adverse biventricular response, so-called remodelling, to key stressors such as right ventricular (RV) pressure-and/or volume-overload, myocardial fibrosis, and electro-mechanical dyssynchrony. In this review, we explore risk factors and mechanisms of biventricular remodelling, from histological to electro-mechanical aspects, and the role of imaging in their assessment. We discuss unsolved challenges and future directions to better understand and treat the long-term sequelae of this complex congenital heart disease.
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Affiliation(s)
- Martina Avesani
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France; Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Zakaria Jalal
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Mark K Friedberg
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Villemain
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maeyls Venet
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giovanni Di Salvo
- Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Jean-Benoît Thambo
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Xavier Iriart
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France.
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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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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.
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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
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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.
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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
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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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10
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Garagiola ML, Thorne SA. Pregnancy Considerations in Tetralogy of Fallot. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:301-313. [PMID: 38161671 PMCID: PMC10755828 DOI: 10.1016/j.cjcpc.2023.09.008] [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: 08/03/2023] [Accepted: 09/12/2023] [Indexed: 01/03/2024]
Abstract
The majority of women with repaired tetralogy of Fallot are able to tolerate pregnancy with a low risk of cardiovascular events. However, proactive contraceptive advice, prepregnancy counselling, and care by a pregnancy heart team with expertise in congenital heart disease are key to ensuring a good outcome for mother and baby. Maternal and fetal risks are increased in the presence of severe valvular stenosis, poorly tolerated arrhythmia, significant ventricular dysfunction, and cyanosis. It is unusual to see cyanotic adults with tetralogy of Fallot, whether unoperated or shunt palliated; pregnancy risks are greatly reduced by completing their repair before pregnancy is undertaken. The multidisciplinary pregnancy heart team should make a risk-stratified pregnancy care plan using a combination of published scoring systems and an individualized assessment of the patient's comorbidities. Low-risk patients may have the majority of their care and give birth in local units, whereas those at high risk should be managed and give birth in a tertiary centre with high-level expertise and intensive care facilities. Age-appropriate conversations about future childbearing and safe and reliable contraception should be part of routine follow-up from teenage years, so that women with tetralogy of Fallot can control their own fertility and make informed decisions about having children.
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Affiliation(s)
- Maria L. Garagiola
- Division of Cardiology, University Health Network and Mount Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Sara A. Thorne
- Division of Cardiology, University Health Network and Mount Sinai Health System, University of Toronto, Toronto, Ontario, Canada
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11
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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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12
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Ait-Ali L, Leonardi B, Alaimo A, Baccano G, Bennati E, Bucciarelli V, Clemente A, Favilli S, Ferroni F, Inserra MC, Lovato L, Maiorano A, Marcora SA, Marrone C, Martini N, Mirizzi G, Pasqualin G, Peritore G, Puppini G, Sandrini C, Raimondi F, Secchi F, Spaziani G, Stagnaro N, Salvadori S, Secinaro A, Tchana B, Trocchio G, Galetti D, Pieroni F, Dalmiani S, Bianco F, Festa P. Overcoming Underpowering in the Outcome Analysis of Repaired-Tetralogy of Fallot: A Multicenter Database from the CMR/CT Working Group of the Italian Pediatric Cardiology Society (SICPed). Diagnostics (Basel) 2023; 13:3255. [PMID: 37892076 PMCID: PMC10606799 DOI: 10.3390/diagnostics13203255] [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: 07/24/2023] [Revised: 08/13/2023] [Accepted: 08/19/2023] [Indexed: 10/29/2023] Open
Abstract
Background: Managing repaired tetralogy of Fallot (TOF) patients is still challenging despite the fact that published studies identified prognostic clinical or imaging data with rather good negative predictive accuracy but weak positive predictive accuracy. Heterogeneity of the initial anatomy, the surgical approach, and the complexity of the mechanism leading to dilation and ventricular dysfunction explain the challenge of predicting the adverse event in this population. Therefore, risk stratification and management of this population remain poorly standardized. Design: The CMR/CT WG of the Italian Pediatric Cardiology Society set up a multicenter observational clinical database of repaired TOF evaluations. This registry will enroll patients retrospectively and prospectively assessed by CMR for clinical indication in many congenital heart diseases (CHD) Italian centers. Data collection in a dedicated platform will include surgical history, clinical data, imaging data, and adverse cardiac events at 6 years of follow-up. Summary: The multicenter repaired TOF clinical database will collect data on patients evaluated by CMR in many CHD centers in Italy. The registry has been set up to allow future research studies in this population to improve clinical/surgical management and risk stratification of this population.
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Affiliation(s)
- Lamia Ait-Ali
- Institute of Clinical Physiology, National Research Institute, 56123 Pisa, Italy; (L.A.-A.); (S.S.)
- Pediatric Cardiology and GUCH Unit, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (C.M.); (N.M.); (P.F.)
| | - Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Children’s Hospital, IRCCS, 00100 Rome, Italy;
| | - Annalisa Alaimo
- U.O.C. Cardiologia Pediatrica, P.O. “G. Di Cristina”, ARNAS Civico, 90123 Palermo, Italy;
| | - Giovanna Baccano
- Department of Pediatric Cardiology, Centro Cardiologico Pediatrico Mediterraneo, 98039 Taormina, Italy;
| | - Elena Bennati
- Pediatric Cardiology, Azienda Ospedaliero-Universitaria Meyer, 50100 Florence, Italy; (E.B.); (S.F.); (F.R.); (G.S.)
| | - Valentina Bucciarelli
- Department of Pediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona “Umberto I, G. M. Lancisi, G. Salesi”, 60123 Ancona, Italy;
| | - Alberto Clemente
- Department of Radiology, Fondazione Toscana Gabriele Monasterio, 56123 Pisa, Italy;
| | - Silvia Favilli
- Pediatric Cardiology, Azienda Ospedaliero-Universitaria Meyer, 50100 Florence, Italy; (E.B.); (S.F.); (F.R.); (G.S.)
| | - Francesca Ferroni
- Department of Radiology, Cardinal Massaia Hospital, 14100 Asti, Italy
| | - Maria Cristina Inserra
- Department of Radiology, University Hospital Vittorio Emanuele Catania, 95100 Catania, Italy;
| | - Luigi Lovato
- Pediatric and Adult Cardiovascular, Thoraco-Abdominal and Emergency Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti 9, 40138 Bologna, Italy;
| | - Antonella Maiorano
- Cardiologia Pediatrica, Ospedale Pediatrico Giovanni XXIII di Bari, Via Amendola 207, 70100 Bari, Italy;
| | - Simona Anna Marcora
- USSD Cardiologia Pediatrica, ASST Grande Ospedale Metropolitano Niguarda, 20126 Milano, Italy;
| | - Chiara Marrone
- Pediatric Cardiology and GUCH Unit, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (C.M.); (N.M.); (P.F.)
| | - Nicola Martini
- Pediatric Cardiology and GUCH Unit, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (C.M.); (N.M.); (P.F.)
| | - Gianluca Mirizzi
- Division of Cardiovascular Medicine, Fondazione G. Monasterio CNR-Regione Toscana, 56123 Pisa, Italy;
| | - Giulia Pasqualin
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milano, Italy; (G.P.); (F.S.)
| | - Giuseppe Peritore
- U.O.C. di Radiodiagnostica, P.O. “G. Di Cristina”, ARNAS Civico, 90123 Palermo, Italy;
| | - Giovanni Puppini
- Department of Radiology, University of Verona, 37100 Verona, Italy;
| | - Camilla Sandrini
- Division of Cardiology, Department of Medicine, University of Verona, 37100 Verona, Italy;
| | - Francesca Raimondi
- Pediatric Cardiology, Azienda Ospedaliero-Universitaria Meyer, 50100 Florence, Italy; (E.B.); (S.F.); (F.R.); (G.S.)
- Department of Cardiology and Cardiovascular Surgery, Papa Giovanni XXIII Hospital, 24100 Bergamo, Italy
| | - Francesco Secchi
- Department of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milano, Italy; (G.P.); (F.S.)
| | - Gaia Spaziani
- Pediatric Cardiology, Azienda Ospedaliero-Universitaria Meyer, 50100 Florence, Italy; (E.B.); (S.F.); (F.R.); (G.S.)
| | - Nicola Stagnaro
- Radiology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy;
| | - Stefano Salvadori
- Institute of Clinical Physiology, National Research Institute, 56123 Pisa, Italy; (L.A.-A.); (S.S.)
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children’s Hospital, IRCCS, 00100 Rome, Italy;
| | - Bertrand Tchana
- Pediatric Cardiology Unit, General and University Hospital, 43121 Parma, Italy;
| | - Gianluca Trocchio
- Pediatric Cardiology Department, Giannina Gaslini Research Institute and Children Hospital, 16100 Genova, Italy;
| | - Davide Galetti
- Inf Department, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (D.G.); (F.P.); (S.D.)
| | - Federica Pieroni
- Inf Department, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (D.G.); (F.P.); (S.D.)
| | - Stefano Dalmiani
- Inf Department, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (D.G.); (F.P.); (S.D.)
| | - Francesco Bianco
- Department of Pediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona “Umberto I, G. M. Lancisi, G. Salesi”, 60123 Ancona, Italy;
| | - Pierluigi Festa
- Pediatric Cardiology and GUCH Unit, Fondazione “G. Monasterio” CNR-Regione Toscana, 541200 Massa, Italy; (C.M.); (N.M.); (P.F.)
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13
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Chan CH, Lam YY, Wong N, Geng L, Zhang J, Ahola V, Zare A, Li RA, Lanner F, Keung W, Cheung YF. Abnormal developmental trajectory and vulnerability to cardiac arrhythmias in tetralogy of Fallot with DiGeorge syndrome. Commun Biol 2023; 6:969. [PMID: 37740059 PMCID: PMC10516936 DOI: 10.1038/s42003-023-05344-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/11/2023] [Indexed: 09/24/2023] Open
Abstract
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Ventricular dysfunction and cardiac arrhythmias are well-documented complications in patients with repaired TOF. Whether intrinsic abnormalities exist in TOF cardiomyocytes is unknown. We establish human induced pluripotent stem cells (hiPSCs) from TOF patients with and without DiGeorge (DG) syndrome, the latter being the most commonly associated syndromal association of TOF. TOF-DG hiPSC-derived cardiomyocytes (hiPSC-CMs) show impaired ventricular specification, downregulated cardiac gene expression and upregulated neural gene expression. Transcriptomic profiling of the in vitro cardiac progenitors reveals early bifurcation, as marked by ectopic RGS13 expression, in the trajectory of TOF-DG-hiPSC cardiac differentiation. Functional assessments further reveal increased arrhythmogenicity in TOF-DG-hiPSC-CMs. These findings are found only in the TOF-DG but not TOF-with no DG (ND) patient-derived hiPSC-CMs and cardiac progenitors (CPs), which have implications on the worse clinical outcomes of TOF-DG patients.
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Affiliation(s)
- Chun-Ho Chan
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yin-Yu Lam
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Nicodemus Wong
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Lin Geng
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Jilin Zhang
- Ming Wai Lau Centre for Reparative Medicine, Hong Kong node, Karolinska Institutet, Units 608-613 Building 15 Science Park, Hong Kong, China
| | - Virpi Ahola
- Ming Wai Lau Centre for Reparative Medicine, Hong Kong node, Karolinska Institutet, Units 608-613 Building 15 Science Park, Hong Kong, China
| | - Aman Zare
- Ming Wai Lau Centre for Reparative Medicine, Hong Kong node, Karolinska Institutet, Units 608-613 Building 15 Science Park, Hong Kong, China
| | - Ronald Adolphus Li
- Ming Wai Lau Centre for Reparative Medicine, Hong Kong node, Karolinska Institutet, Units 608-613 Building 15 Science Park, Hong Kong, China
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong - Karolinska Institutet Collaboration in Regenerative Medicine, The University of Hong Kong, Hong Kong, China
| | - Fredrik Lanner
- Ming Wai Lau Centre for Reparative Medicine, Stockholm node, Karolinska Institutet, Solnavagen 9, 17165, Stockholm, Sweden
- Department of Clinical Sciences, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Division of Obstetrics and Gynecology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Wendy Keung
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong - Karolinska Institutet Collaboration in Regenerative Medicine, The University of Hong Kong, Hong Kong, China
| | - Yiu-Fai Cheung
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China.
- Ming Wai Lau Centre for Reparative Medicine, Hong Kong node, Karolinska Institutet, Units 608-613 Building 15 Science Park, Hong Kong, China.
- Dr. Li Dak-Sum Research Centre, The University of Hong Kong - Karolinska Institutet Collaboration in Regenerative Medicine, The University of Hong Kong, Hong Kong, China.
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14
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Helal AM, Baho HA, Elmahrouk AF, Mashali MH. PR and QRS interval changes after transcatheter pulmonary valve replacement in children. Egypt Heart J 2023; 75:66. [PMID: 37486586 PMCID: PMC10366049 DOI: 10.1186/s43044-023-00394-x] [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: 05/29/2023] [Accepted: 07/20/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Changes in PR intervals after transcatheter pulmonary valve replacement (TCPVR) have not been thoroughly evaluated in children. This study evaluated the changes in PR and QRS intervals six months after TCPVR in children with congenital heart disease. RESULTS This study included 41 patients who underwent TCPVR from 2010 to 2022. ECG of patients was reviewed before and six months after TCPVR, and the PR and QRS intervals were reported. Right ventricular systolic pressure (RVSP) was retrieved indirectly from echocardiography and compared pre- and 6-months after TPVR. The median age was 13 years (25th-75th percentiles: 11-16), and 61% were males. The preoperative diagnosis was tetralogy of Fallot (n = 29, 71%), transposition of great vessels (n = 4, 10%), common arterial trunk (n = 3, 7%), pulmonary valve stenosis (n = 3, 7%) and pulmonary atresia (n = 2, 5%). The Melody valve was used in 30 patients, and Edwards Sapien was used in 11 patients. RVSP was significantly reduced six months after the procedure (pre-RVSP 40 (30-55) mmHg vs. post-RVSP 25 (20-35) mmHg; P < 0.001). The PR interval was 142 (132-174) msec before TPVR and 146 (132-168) msec post-TCPVR (P = 0.442). Post-TPVR PR was positively related to the pre-PR (β: 0.79 (0.66-0.93), P < 0.001) and inversely related to the right ventricular outflow tract size (- 1.48 (- 2.76 to - 0.21), P = 0.023). The pre-TPVR QRS was 130 (102-146) msec, and the post-TPVR QRS was 136 (106-144) msec (P = 0.668). CONCLUSIONS In children undergoing TCPVR, the PR and QRS intervals did not change significantly during a 6-month follow-up.
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Affiliation(s)
- Abdelmonem M Helal
- Pediatric Cardiology Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Pediatrics, Pediatric Cardiology Division, Cairo University, Cairo, Egypt
| | - Haysam A Baho
- Pediatric Cardiology Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ahmed F Elmahrouk
- Division of Cardiac Surgery, Cardiovascular Department, King Faisal Specialist Hospital and Research Center, MBC J-16, P.O. Box:40047, 21499, Jeddah, Saudi Arabia.
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt.
| | - Mohamed H Mashali
- Pediatric Cardiology Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
- Department of Pediatrics, Pediatric Cardiology Division, Cairo University, Cairo, Egypt
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15
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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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16
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Hnatkova K, Andršová I, Novotný T, Britton A, Shipley M, Vandenberk B, Sprenkeler DJ, Junttila J, Reichlin T, Schlögl S, Vos MA, Friede T, Bauer A, Huikuri HV, Willems R, Schmidt G, Franz MR, Sticherling C, Zabel M, Malik M. QRS micro-fragmentation as a mortality predictor. Eur Heart J 2022; 43:4177-4191. [PMID: 35187560 PMCID: PMC9584751 DOI: 10.1093/eurheartj/ehac085] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Fragmented QRS complex with visible notching on standard 12-lead electrocardiogram (ECG) is understood to represent depolarization abnormalities and to signify risk of cardiac events. Depolarization abnormalities with similar prognostic implications likely exist beyond visual recognition but no technology is presently suitable for quantification of such invisible ECG abnormalities. We present such a technology. METHODS AND RESULTS A signal processing method projects all ECG leads of the QRS complex into optimized three perpendicular dimensions, reconstructs the ECG back from this three-dimensional projection, and quantifies the difference (QRS 'micro'-fragmentation, QRS-μf) between the original and reconstructed signals. QRS 'micro'-fragmentation was assessed in three different populations: cardiac patients with automatic implantable cardioverter-defibrillators, cardiac patients with severe abnormalities, and general public. The predictive value of QRS-μf for mortality was investigated both univariably and in multivariable comparisons with other risk factors including visible QRS 'macro'-fragmentation, QRS-Mf. The analysis was made in a total of 7779 subjects of whom 504 have not survived the first 5 years of follow-up. In all three populations, QRS-μf was strongly predictive of survival (P < 0.001 univariably, and P < 0.001 to P = 0.024 in multivariable regression analyses). A similar strong association with outcome was found when dichotomizing QRS-μf prospectively at 3.5%. When QRS-μf was used in multivariable analyses, QRS-Mf and QRS duration lost their predictive value. CONCLUSION In three populations with different clinical characteristics, QRS-μf was a powerful mortality risk factor independent of several previously established risk indices. Electrophysiologic abnormalities that contribute to increased QRS-μf values are likely responsible for the predictive power of visible QRS-Mf.
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Affiliation(s)
- Katerina Hnatkova
- National Heart and Lung Institute, Imperial College, ICTEM, Hammersmith Campus, 72 Du Cane Road, Shepherd's Bush, London W12 0NN, UK
| | - Irena Andršová
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Tomáš Novotný
- Department of Internal Medicine and Cardiology, University Hospital Brno, Brno, Czech Republic.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
| | - Annie Britton
- Research Department of Epidemiology and Public Health, University College London, UK
| | - Martin Shipley
- Research Department of Epidemiology and Public Health, University College London, UK
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - David J Sprenkeler
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juhani Junttila
- Medical Research Center Oulu, University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Tobias Reichlin
- Department of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Simon Schlögl
- Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Marc A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tim Friede
- German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Axel Bauer
- University Hospital for Internal Medicine III, Medical University Innsbruck, Innsbruck, Austria
| | - Heikki V Huikuri
- Medical Research Center Oulu, University Central Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Rik Willems
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Georg Schmidt
- Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.,German Center for Cardiovascular Research Partner Site Munich Heart Alliance, Munich, Germany
| | - Michael R Franz
- Veteran Affairs and Georgetown University Medical Centers, Washington, DC, USA
| | | | - Markus Zabel
- Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany.,German Center of Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Marek Malik
- National Heart and Lung Institute, Imperial College, ICTEM, Hammersmith Campus, 72 Du Cane Road, Shepherd's Bush, London W12 0NN, UK.,Department of Internal Medicine and Cardiology, Masaryk University, Brno, Czech Republic
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17
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 713] [Impact Index Per Article: 356.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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18
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Fragmented QRS: As an electrocardiographic prognostic marker in Tetralogy of Fallot. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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19
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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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20
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Nikus K, Punkka O, Barbosa-Barros R, Daminello-Raimundo R, de Abreu LC, Pérez-Riera AR. Northwest axis in the electrocardiogram - A sign of right ventricular remodeling in tetralogy of Fallot. A case report. J Electrocardiol 2022; 74:101-103. [PMID: 36088787 DOI: 10.1016/j.jelectrocard.2022.08.011] [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: 05/19/2022] [Revised: 08/25/2022] [Accepted: 08/28/2022] [Indexed: 12/13/2022]
Abstract
The typical ECG changes in tetralogy of Fallot are right axis deviation, large R waves in the anterior precordial leads and large S waves in the lateral precordial leads. We present a patient with extreme deviation of the frontal QRS axis between -90° and ± 180°. The child underwent open heart surgery twice before one year of age and a third time at nine years of age. The axis change persisted into adulthood.
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Affiliation(s)
- Kjell Nikus
- Heart Center, Tampere University Hospital, Finland; Faculty of Medicine and Health Technology, Tampere University, Finland.
| | - Olli Punkka
- Faculty of Medicine and Health Technology, Tampere University, Finland
| | - Raimundo Barbosa-Barros
- Coronary Center of the Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Rodrigo Daminello-Raimundo
- Laboratório de Delineamento de Pesquisas e Escrita Científica, Centro Universitário FMABC, Santo André, São Paulo, Brazil
| | - Luiz Carlos de Abreu
- Laboratório de Delineamento de Pesquisas e Escrita Científica, Centro Universitário FMABC, Santo André, São Paulo, Brazil; Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Andrés Ricardo Pérez-Riera
- Laboratório de Delineamento de Pesquisas e Escrita Científica, Centro Universitário FMABC, Santo André, São Paulo, Brazil; Clínica Médica e suas Especialidades, Universidade Uninove, Mauá, SP, Brazil
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21
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Waldmann V, Bouzeman A, Duthoit G, Koutbi L, Bessière F, Labombarda F, Marquié C, Gourraud JB, Mondoly P, Sellal JM, Bordachar P, Hermida A, Al Arnaout A, Anselme F, Audinet C, Bernard Y, Boveda S, Bun SS, Chassignolle M, Clerici G, Da Costa A, de Guillebon M, Defaye P, Elbaz N, Eschalier R, Garcia R, Guenancia C, Guy-Moyat B, Halimi F, Irles D, Iserin L, Jourda F, Ladouceur M, Lagrange P, Laredo M, Mansourati J, Massoulié G, Mathiron A, Maury P, Messali A, Narayanan K, Nguyen C, Ninni S, Perier MC, Pierre B, Pujadas P, Sacher F, Sagnol P, Sharifzadehgan A, Walton C, Winum P, Zakine C, Fauchier L, Martins R, Pasquié JL, Thambo JB, Jouven X, Combes N, Marijon E. Sex Differences in Outcomes of Tetralogy of Fallot Patients With Implantable Cardioverter-Defibrillators. JACC Clin Electrophysiol 2022; 8:1304-1314. [DOI: 10.1016/j.jacep.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
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22
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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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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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24
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Wilson LH, Chowdhury SM, Jackson LB. QRS fragmentation and prolongation as predictors of exercise capacity in patients after Fontan palliation. Pacing Clin Electrophysiol 2022; 45:786-796. [PMID: 35510731 DOI: 10.1111/pace.14514] [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] [Received: 09/19/2021] [Revised: 04/01/2022] [Accepted: 04/29/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Patients with Fontan anatomy are at increased risk for exercise intolerance and early morbidity and mortality. QRS complex fragmentation (fQRS) and prolongation have been studied in multiple heart diseases, but their clinical importance is unknown in the Fontan population. METHODS A retrospective cross-sectional study was performed. ECGs were evaluated for QRS prolongation (>98 %ile for age) and fQRS [ ≥3 R-waves/ notches in the R/S complex (more than 2 in RBBB) in ≥2 contiguous leads]. The primary outcome measures was CPET performance. RESULTS Ninety patients (median age 18 years, 57% male, 59% RV dominant) were included; 13% had fQRS and 31% had prolonged QRS. Demographically, patients with fQRS or prolonged QRS were like those without. Peak VO2 (64% vs 63%, p 0.45), VE/VCO2 slope (85% vs 88%, p = 0.74), and O2 pulse (149% vs 129%, p = 0.83) were similar in the fQRS group versus those without. Upon multi-variable regression, body mass index (β = -0.38, p < 0.01) and QRS duration (β = -0.29, p < 0.01) were independently associated with % predicted VO2; fQRS was not. Lower cardiac index (2.2 vs 2.8 L/min/m2, p = 0.03) and higher ventricular end-diastolic pressure (13 vs 10 mmHg, p = 0.02) was seen with fQRS. CONCLUSIONS QRS fragmentation is present in patients with Fontan physiology. fQRS showed no association with CPET performance but was related to invasive hemodynamic markers of ventricular performance. QRS duration may be a better predictor of exercise function following Fontan. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Lucas H Wilson
- Children's Heart Center, The Medical University of South Carolina, South Carolina, USA
| | - Shahryar M Chowdhury
- Children's Heart Center, The Medical University of South Carolina, South Carolina, USA
| | - Lanier B Jackson
- Children's Heart Center, The Medical University of South Carolina, South Carolina, USA
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25
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Zaidi AN. Tetralogy of Fallot: management of residual hemodynamic and electrophysiological abnormalities. Heart 2021; 108:1408-1414. [PMID: 34949687 DOI: 10.1136/heartjnl-2020-316668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Ali N Zaidi
- Mount Sinai Adult Congenital Heart Disease Center, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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26
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Buntharikpornpun R, Jaruratanasirikul S, Roymanee S, Jarutach J, Wongwaitaweewong K, Sangthong R. Correlation Between Fragmented QRS and Ventricular Function from Cardiac Magnetic Resonance in Patients with Repaired Tetralogy of Fallot. Pediatr Cardiol 2021; 42:1713-1721. [PMID: 34110460 DOI: 10.1007/s00246-021-02655-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
Fragmented QRS is an abnormal sign in an ECG resulting from ventricular dyssynchrony. The presence of fragmented QRS (fQRS) is related to mortality in patients with repaired tetralogy of Fallot (rTOF). This study aimed to analyze the correlations between fQRS and ventricular function parameters from cardiac magnetic resonance (CMR) images. A total of 54 patients with rTOF or repaired DORV, TOF type who had been investigated by CMR at Songklanagarind Hospital from January 2012 to August 2019 were retrospectively reviewed. Most of the patients (47 patients, 87%) were diagnosed with TOF and most of these (57.4%) were treated with a transannular patch (TAP) on the right ventricular outflow tract (RVOT). Forty-four patients (81%) had fQRS. The median time interval between EKG and CMR was 4.2 months (IQR 1.1, 6.9). Patients with fQRS had significantly higher RVEDVi (145.6 [IQR 121.1, 173.1) vs. 115.9 [IQR 96.2, 146.9] mL/m2, p = 0.037), higher RVESVi (82.5 [IQR 62.9, 100.8] vs. 58.6 [IQR 46, 77.2] mL/m2, p = 0.032) and higher RVEDV/LVEDV ratio [1.6 (IQR 1.4, 1.9) vs. 1.4 (IQR 1.3, 1.5), p = 0.026]. The extent of fQRS was significantly associated with an increase in RVEDVi (r = 0.39, p = 0.004) and RVESVi (r = 0.45, p < 0.001) but a decrease in RVEF (r = - 0.37, p = 0.006). Fragmented QRS had higher sensitivity and lower specificity than prolonged QRS duration (≥ 160 ms) to predict all of the parameters indicating pulmonary valve replacement (PVR). Patients with rTOF who had fQRS were significantly associated with RV dilatation. The extent of fQRS had only low to moderate correlation with right ventricular parameters (RVEDVi, RVESVi and RVEF). Fragmented QRS could be used for early detection of RV dilatation and the need for PVR in patients with rTOF.
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Affiliation(s)
- Rujira Buntharikpornpun
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Somchit Jaruratanasirikul
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Supaporn Roymanee
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Jirayut Jarutach
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Kanjarut Wongwaitaweewong
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Rassamee Sangthong
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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27
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Lubocka P, Sabiniewicz R. What Is the Importance of Electrocardiography in the Routine Screening of Patients with Repaired Tetralogy of Fallot? J Clin Med 2021; 10:jcm10194298. [PMID: 34640313 PMCID: PMC8509678 DOI: 10.3390/jcm10194298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/15/2021] [Accepted: 09/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background: In patients following complete repair of the tetralogy of Fallot, the duration of the QRS complex is associated with the size and mechanical function of the right ventricle, which are contemporarily assessed by cardiac magnetic resonance (CMR). Methods: 38 patients aged 18.0–54.9 years (median age 24.9 years) who had undergone complete repair of the tetralogy of Fallot were examined using CMR and concomitant 24 h ambulatory electrocardiography monitoring. We used statistical analysis to investigate the correlations between electrocardiographic parameters (heart rate, HR; PQ interval, PQ; QRS duration, QRS; and corrected QT interval, QTc) and CMR results (right ventricular ejection fraction, RVEF; right ventricular end-diastolic volume index, RVEDVI; and right ventricular end-systolic volume index, RVESVI) for patients after early and late repair. Results: The ECG-based parameters were not correlated with time since repair. There were significant correlations between QRS duration and RVEF (r = −0.61), RVEDVI (r = 0.56), and RVESVI (r = 0.54) for early operated patients but not for late-operated patients. No other substantial correlations were reported. Conclusion: Despite its role in screening for arrhythmias, electrocardiography has a limited role as a predictor of morphology and function of the right ventricle in patients after repair of the tetralogy of Fallot.
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28
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Wülfers EM, Greiner J, Giese M, Madl J, Kroll J, Stiller B, Kohl P, Rog-Zielinska EA, Fürniss HE. Quantitative collagen assessment in right ventricular myectomies from patients with tetralogy of Fallot. Europace 2021; 23:i38-i47. [PMID: 33404047 PMCID: PMC7943371 DOI: 10.1093/europace/euaa389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/10/2020] [Indexed: 11/16/2022] Open
Abstract
Aims Patients with tetralogy of Fallot (TOF) are often affected by right ventricular fibrosis, which has been associated with arrhythmias. This study aimed to assess fibrosis distribution in right ventricular outflow tract (RVOT) myocardium of TOF patients to evaluate the utility of single histology-section analyses, and to explore the possibility of fibrosis quantification in unlabelled tissue by second harmonic generation imaging (SHGI) as an alternative to conventional histology-based assays. Methods and results We quantified fibrosis in 11 TOF RVOT samples, using a tailor-made automated image analysis method on Picrosirius red-stained sections. In a subset of samples, histology- and SHGI-based fibrosis quantification approaches were compared. Fibrosis distribution was highly heterogeneous, with significant and comparable variability between and within samples. We found that, on average, 67.8 mm2 of 10 µm thick, histologically processed tissue per patient had to be analysed for accurate fibrosis quantification. SHGI provided data faster and on live tissue, additionally enabling quantification of collagen anisotropy. Conclusion Given the high intra-individual heterogeneity, fibrosis quantification should not be conducted on single sections of TOF RVOT myectomies. We provide an analysis algorithm for fibrosis quantification in histological images, which enables the required extended volume analyses in these patients.
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Affiliation(s)
- Eike M Wülfers
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Joachim Greiner
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Max Giese
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Josef Madl
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Johannes Kroll
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Brigitte Stiller
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Department of Congenital Heart Disease and Paediatric Cardiology, University Heart Center Freiburg-Bad Krozingen, Medical Center - University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Peter Kohl
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Department of Cardiovascular Surgery, University Heart Center Freiburg-Bad Krozingen, Medical Center - University of Freiburg, Faculty of Medicine, 79106 Freiburg, Germany
| | - Eva A Rog-Zielinska
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
| | - Hannah E Fürniss
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center- University of Freiburg, Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany.,Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, Medical Center-University of Freiburg,Faculty of Medicine, Elsässer Straße 2Q, 79110 Freiburg, Germany
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Abstract
BACKGROUND The adult population of repaired tetralogy of Fallot is increasing and at risk of pre-mature death and arrhythmia. This study evaluates risk factors for adverse outcome and the effect of pulmonary valve replacement within a national cohort. METHODS A retrospective cohort study of 341 adult repaired tetralogy of Fallot (16-72 years) managed through a single national service was undertaken incorporating over 1200 patient-years of follow-up. Demographics, cardiopulmonary exercise testing, cardiac magnetic resonance, reintervention (including pulmonary valve replacement), and clinical events were analysed. The influence of these parameters on a primary outcome (death or arrhythmia) was evaluated. RESULTS Compared with an age-/gender-matched population, patients experienced a reduced survival, particularly males over 55 years (standardised mortality ratio : 6.12, 95% CI: 1.64-15.66, p = 0.004). Cox proportional hazards modelling identified increased indexed right ventricle (RV) end-diastolic volume (hazard ratio (HR): 2.86, 95% CI: 1.4-5.85, p = 0.004) and female gender (HR (male): 0.37, 95% CI: 0.14-0.98, p = 0.045) to be predictors significantly associated with the primary outcome. Pulmonary valve replacement undertaken at indexed RV end-diastolic volume = 145 ml/m2 reduced RV volumes and QRS duration but did not improve cardiopulmonary exercise testing nor NYHA class. Pulmonary valve replacement during cohort period was associated with increased risk of primary outcome (HR: 2.82, 95% CI: 1.36-5.86, p = 0.005). CONCLUSIONS Although the majority of adult tetralogy of Fallot were asymptomatic in NYHA 1, cardiopulmonary exercise testing revealed important deficits. Tetralogy of Fallot survival was reduced compared to the general population. Female gender and increasing RV end-diastolic volume predicted adverse events. Pulmonary valve replacement reduced RV volumes and QRS duration but did not improve primary outcome.
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Abstract
Introduction: Advancements in surgery and management have resulted in a growing population of aging adults with tetralogy of Fallot (TOF). As a result, there has been a parallel growth in late complications associated with the sequelae from the underlying cardiac anomalies as well as the surgical and other interventional treatments.Areas covered: Here, we review challenges related to an aging population of patients with TOF, particularly late complications, and highlight advances in management and key areas for future research. Pulmonary regurgitation, heart failure, arrhythmias, and aortic complications are some of these late complications. There is also a growing incidence of acquired cardiovascular disease, obesity, and diabetes associated with aging. Management of these late complications and acquired comorbidities continues to evolve as research provides insights into long-term outcomes from medical therapies and surgical interventions.Expert opinion: The management of an aging TOF population will continue to transform with advances in imaging technologies to identify subclinical disease and valve replacement technologies that will prevent and mitigate disease progression. In the coming years, we speculate that there will be more data to support the use of novel heart failure therapies in TOF and consensus guidelines on the management of refractory arrhythmias and aortic complications.
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Affiliation(s)
- Jennifer P Woo
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
| | - Doff B McElhinney
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California, USA
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, California, USA
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Ma K, Qi L, Ren L, Zhang B, Liu R, Yang Y, Wang G, Zhang S, Li S. Impact of electrophysiological features acquired after anatomical repair of congenital corrected transposition of the great arteries on late mortality and ventricular dysfunction. Eur J Cardiothorac Surg 2021; 59:839-846. [PMID: 33313849 DOI: 10.1093/ejcts/ezaa433] [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] [Received: 05/05/2020] [Revised: 10/07/2020] [Accepted: 10/18/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In patients with anatomically repaired congenitally corrected transposition of the great arteries, the impact of electrophysiological features on postoperative ventricular dysfunction remains less well known. Our goal was to investigate the role of fragmented QRS and QRS duration in mortality and systemic ventricular dysfunction after anatomical repair of corrected transposed great arteries. METHODS Consecutive patients who underwent anatomical repair in our institution from January 2005 to December 2017 were enrolled in this retrospective analysis. Fragmented QRS was defined as ≥1 discontinuous deflections in narrow QRS complexes, and ≥2 in wide QRS complexes, in 2 contiguous electrocardiogram leads. The primary end point was a composite of all-cause mortality and systemic ventricular dysfunction. RESULTS A total of 74 patients were included. Among them, 30, 15 and 29 underwent the Senning arterial switch, the Senning Rastelli and the hemi-Mustard/bidirectional Glenn/Rastelli procedures, respectively. The primary end point occurred in 9 (12.2%) patients and included 7 late deaths and 2 cases of late-onset systemic ventricular dysfunction. Fragmented QRS and QRS prolongation were noted in 19 (25.7%) and 21 (28.4%) patients, respectively. In patients with the primary end point, QRS fragmentation (6/9 vs 10/65; P < 0.001) and QRS prolongation (6/9 vs 15/65; P = 0.013) were noted more frequently than in patients without the primary end point. No statistical differences in these electrocardiogram findings were found among patients treated with 3 surgical strategies. CONCLUSIONS Appearance of QRS fragmentation or QRS prolongation is associated with death or ventricular dysfunction in anatomically repaired corrected transposition of the great arteries. Although there is a trend that QRS fragmentation and QRS prolongation appear more frequently in patients who had the Senning-arterial switch operation, there is no statistically significant difference associated with these electrocardiogram features among varied procedures.
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Affiliation(s)
- Kai Ma
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lei Qi
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Lan Ren
- Department of Cardiology, Beijing Jishuitan Hospital, Beijing, China
| | - Benqing Zhang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Rui Liu
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yang Yang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Guanxi Wang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Sen Zhang
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Paediatric Cardiac Surgery Center, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Disease, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Impact of Pulmonary Valve Replacement on Ventricular Arrhythmias in Patients With Tetralogy of Fallot and Implantable Cardioverter-Defibrillator. JACC Clin Electrophysiol 2021; 7:1285-1293. [PMID: 33933408 DOI: 10.1016/j.jacep.2021.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study aimed to assess the impact of pulmonary valve replacement (PVR) on ventricular arrhythmias burden in a population of tetralogy of Fallot (TOF) patients with continuous cardiac monitoring by implantable cardioverter-defibrillators (ICDs). BACKGROUND Sudden cardiac death is a major cause of death in TOF, and right ventricular overload is commonly considered to be a potential trigger for ventricular arrhythmias. METHODS Data were analyzed from a nationwide French ongoing study (DAI-T4F) including all TOF patients with an ICD since 2000. Survival data with recurrent events were used to compare the burden of appropriate ICD therapies before and after PVR in patients who underwent PVR over the study period. RESULTS A total of 165 patients (mean age 42.2 ± 13.3 years, 70.1% male) were included from 40 centers. Over a median follow-up period of 6.8 (interquartile range: 2.5 to 11.4) years, 26 patients (15.8%) underwent PVR. Among those patients, 18 (69.2%) experienced at least 1 appropriate ICD therapy. When considering all ICD therapies delivered before (n = 62) and after (n = 16) PVR, the burden of appropriate ICD therapies was significantly lower after PVR (HR: 0.21; 95% confidence interval [CI]: 0.08 to 0.56; p = 0.002). Respective appropriate ICD therapies rates per 100 person-years were 44.0 (95% CI: 35.7 to 52.5) before and 13.2 (95% CI: 7.7 to 20.5) after PVR (p < 0.001). In the overall cohort, PVR before ICD implantation was also independently associated with a lower risk of appropriate ICD therapy in primary prevention patients (HR: 0.29 [95% CI: 0.10 to 0.89]; p = 0.031). CONCLUSIONS In this cohort of high-risk TOF patients implanted with an ICD, the burden of appropriate ICD therapies was significantly reduced after PVR. While optimal indications and timing for PVR are debated, these findings suggest the importance of considering ventricular arrhythmias in the overall decision-making process. (French National Registry of Patients With Tetralogy of Fallot and Implantable Cardioverter Defibrillator [DAI-T4F]; NCT03837574).
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Köbe J, Willy K, Eckardt L, Baumgartner H, Wasmer K. Narrative review of: risk stratification and implantable cardioverter-defibrillator therapy in adults with congenital heart disease. Cardiovasc Diagn Ther 2021; 11:538-549. [PMID: 33968632 DOI: 10.21037/cdt-20-633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Fortunately, the population of adults with congenital heart disease (ACHD) is growing due to improved operation techniques. Life expectancy is continuously rising, nevertheless, sudden cardiac death is one of the leading causes of mortality in ACHD late after initial diagnosis. Risk stratification in ACHD remains challenging as large study results are missing, congenital defects and operation methods differ considerably between individual patients and results from acquired heart diseases are often not conferrable. The purpose of this narrative review is to objectively summarize the current knowledge on arrhythmogenic risk of ACHD and to give an overview on implantable cardioverter-defibrillator (ICD) therapy in this collective. Remarkable progress has been made in electrophysiological understanding of critical areas of slow conduction especially in patients with Tetralogy of Fallot (ToF). In patients with transposition of the great arteries after atrial baffling (Mustard/Senning procedure) atrial arrhythmias play a crucial role in sudden cardiac death. ICD therapy in ACHD may pose special technical challenges due to limited access for intracardiac leads. The introduction of the totally subcutaneous ICD improved therapeutic options for ACHD especially when contraindications for transvenous leads are present. Risk stratification in ACHD has to be seen as a team approach, requires thorough understanding of congenital heart defects and the operation techniques and needs unconventional technical approaches in some cases.
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Affiliation(s)
- Julia Köbe
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany
| | - Kevin Willy
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany
| | - Helmut Baumgartner
- Department of Cardiology III, Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Kristina Wasmer
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Muenster, Germany
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Chávez-Saldívar S, Mego JC, Tauma-Arrué A, Coronado J, Luis-Ybáñez O, Bravo-Jaimes K. [The adult with tetralogy of fallot: what the clinical cardiologist needs to know]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2021; 2:121-129. [PMID: 38274563 PMCID: PMC10809779 DOI: 10.47487/apcyccv.v2i2.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/26/2021] [Indexed: 01/27/2024]
Abstract
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. After more than seven decades of the first palliative surgery, TOF prognosis has changed dramatically. The prevalence of TOF is approximately 3 per 10 000 births, representing 7 to 10% of congenital heart disease. With a higher survival into adulthood, the clinical cardiologist faces challenges in the management of this population, from severe pulmonary regurgitation to heart failure and ventricular arrhythmias. Its prevalence is approximately 3 per 10 000 live births, representing 7 to 10% of congenital heart disease. This review will describe the most relevant aspects of the care of adult patients with this disease.
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Affiliation(s)
- Samantha Chávez-Saldívar
- Facultad de Medicina San Fernando. Universidad Nacional Mayor de San Marcos. Lima, Perú.Universidad Nacional Mayor de San MarcosFacultad de Medicina San FernandoUniversidad Nacional Mayor de San MarcosLimaPeru
- Sociedad Científica de San Fernando. Lima, Perú.Sociedad Científica de San FernandoLimaPerú
| | - Juan Carlos Mego
- Facultad de Medicina San Fernando. Universidad Nacional Mayor de San Marcos. Lima, Perú.Universidad Nacional Mayor de San MarcosFacultad de Medicina San FernandoUniversidad Nacional Mayor de San MarcosLimaPeru
- Sociedad Científica de San Fernando. Lima, Perú.Sociedad Científica de San FernandoLimaPerú
| | - Astrid Tauma-Arrué
- Facultad de Medicina San Fernando. Universidad Nacional Mayor de San Marcos. Lima, Perú.Universidad Nacional Mayor de San MarcosFacultad de Medicina San FernandoUniversidad Nacional Mayor de San MarcosLimaPeru
- Sociedad Científica de San Fernando. Lima, Perú.Sociedad Científica de San FernandoLimaPerú
| | - Joel Coronado
- Facultad de Medicina San Fernando. Universidad Nacional Mayor de San Marcos. Lima, Perú.Universidad Nacional Mayor de San MarcosFacultad de Medicina San FernandoUniversidad Nacional Mayor de San MarcosLimaPeru
- Sociedad Científica de San Fernando. Lima, Perú.Sociedad Científica de San FernandoLimaPerú
| | - Odalis Luis-Ybáñez
- Facultad de Medicina San Fernando. Universidad Nacional Mayor de San Marcos. Lima, Perú.Universidad Nacional Mayor de San MarcosFacultad de Medicina San FernandoUniversidad Nacional Mayor de San MarcosLimaPeru
- Sociedad Científica de San Fernando. Lima, Perú.Sociedad Científica de San FernandoLimaPerú
| | - Katia Bravo-Jaimes
- Ahmanson/UCLA Adult Congenital Heart Disease Center. University of California. Los Angeles, Estados Unidos.University of CaliforniaAhmanson/UCLA Adult Congenital Heart Disease CenterUniversity of CaliforniaLos AngelesUSA
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Abstract
The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.
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36
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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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Waldmann V, Combes N, Ladouceur M, Celermajer DS, Iserin L, Gatzoulis MA, Khairy P, Marijon E. Understanding Electrocardiography in Adult Patients With Congenital Heart Disease. JAMA Cardiol 2020; 5:1435-1444. [DOI: 10.1001/jamacardio.2020.3416] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Victor Waldmann
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | - Nicolas Combes
- Pasteur Clinic, Toulouse, France
- Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Department of Cardiology, European Georges Pompidou Hospital, Paris, France
| | | | - Paul Khairy
- Montreal Heart Institute, Montreal, Quebec, Canada
| | - Eloi Marijon
- Cardiac Electrophysiology Section, European Georges Pompidou Hospital, Paris, France
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Risk Factors for Mortality and Ventricular Tachycardia in Patients With Repaired Tetralogy of Fallot: A Systematic Review and Meta-analysis. Can J Cardiol 2020; 36:1815-1825. [DOI: 10.1016/j.cjca.2020.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/14/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022] Open
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Santens B, Van De Bruaene A, De Meester P, D'Alto M, Reddy S, Bernstein D, Koestenberger M, Hansmann G, Budts W. Diagnosis and treatment of right ventricular dysfunction in congenital heart disease. Cardiovasc Diagn Ther 2020; 10:1625-1645. [PMID: 33224777 DOI: 10.21037/cdt-20-370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Right ventricular (RV) function is important for clinical status and outcomes in children and adults with congenital heart disease (CHD). In the normal RV, longitudinal systolic function is the major contributor to global RV systolic function. A variety of factors contribute to RV failure including increased pressure- or volume-loading, electromechanical dyssynchrony, increased myocardial fibrosis, abnormal coronary perfusion, restricted filling capacity and adverse interactions between left ventricle (LV) and RV. We discuss the different imaging techniques both at rest and during exercise to define and detect RV failure. We identify the most important biomarkers for risk stratification in RV dysfunction, including abnormal NYHA class, decreased exercise capacity, low blood pressure, and increased levels of NTproBNP, troponin T, galectin-3 and growth differentiation factor 15. In adults with CHD (ACHD), fragmented QRS is independently associated with heart failure (HF) symptoms and impaired ventricular function. Furthermore, we discuss the different HF therapies in CHD but given the broad clinical spectrum of CHD, it is important to treat RV failure in a disease-specific manner and based on the specific alterations in hemodynamics. Here, we discuss how to detect and treat RV dysfunction in CHD in order to prevent or postpone RV failure.
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Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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41
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Egbe AC, Pellikka PA, Afzal A, Jain V, Thotamgari S, Miranda WR, Connolly HM. Prognostic Implications of Left Ventricular Cardiomyopathy in Adults With Tetralogy of Fallot. CJC Open 2020; 2:1-7. [PMID: 32159130 PMCID: PMC7063625 DOI: 10.1016/j.cjco.2019.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Despite the significant risk of cardiovascular mortality after tetralogy of Fallot (TOF) repair, there are limited data about left ventricular (LV) cardiomyopathy in this population, thus creating important knowledge gaps. This study aims to address some of these knowledge gaps by describing the risk and prognostic implications of LV systolic dysfunction (LVD) after TOF repair. METHODS We performed a cohort study of adult patients after TOF repair with an echocardiographic assessment of LV ejection fraction (LVEF) to determine the association between LVD and cardiovascular events, defined as sustained ventricular tachycardia, aborted sudden death, heart transplantation, or death. Prevalent and incidence LVD were defined as LVEF < 50% at baseline or new decrease in LVEF to < 50% during follow-up, respectively. RESULTS Of 574 patients (age 38 ± 13 years), the baseline LVEF was 57% ± 9% and 68 (12%) had prevalent LVD. Cardiovascular events occurred in 126 patients (22%) during 10.5 ± 6.2 years of follow-up. LVEF was an independent predictor of mortality (hazard ratio, 1.16; 95% confidence interval, 1.16-1.24; P = 0.003) per 5%-point decrease in LVEF. Among the 357 patients with preserved LVEF and echocardiographic follow-up, incident LVD occurred in 23 (6%) during 3.8 ± 1.6 years of follow-up. Event-free survival was significantly lower in patients with incident LVD compared with patients without incident LVD (87% vs 71%, P = 0.021). CONCLUSION Prevalent and incident LVD occurred in 12% and 6% of this cohort, respectively, and were associated with lower event-free survival. Incident LVD suggests the presence of subclinical LV cardiomyopathy, and further studies are required to determine optimal strategies for diagnosing and treating subclinical LV cardiomyopathy to improve outcomes in the population with TOF.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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42
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Bacharova L. Missing Link between Molecular Aspects of Ventricular Arrhythmias and QRS Complex Morphology in Left Ventricular Hypertrophy. Int J Mol Sci 2019; 21:E48. [PMID: 31861705 PMCID: PMC6982310 DOI: 10.3390/ijms21010048] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 12/27/2022] Open
Abstract
The aim of this opinion paper is to point out the knowledge gap between evidence on the molecular level and clinical diagnostic possibilities in left ventricular hypertrophy (LVH) regarding the prediction of ventricular arrhythmias and monitoring the effect of therapy. LVH is defined as an increase in left ventricular size and is associated with increased occurrence of ventricular arrhythmia. Hypertrophic rebuilding of myocardium comprises interrelated processes on molecular, subcellular, cellular, tissue, and organ levels affecting electrogenesis, creating a substrate for triggering and maintaining arrhythmias. The knowledge of these processes serves as a basis for developing targeted therapy to prevent and treat arrhythmias. In the clinical practice, the method for recording electrical phenomena of the heart is electrocardiography. The recognized clinical electrocardiogram (ECG) predictors of ventricular arrhythmias are related to alterations in electrical impulse propagation, such as QRS complex duration, QT interval, early repolarization, late potentials, and fragmented QRS, and they are not specific for LVH. However, the simulation studies have shown that the QRS complex patterns documented in patients with LVH are also conditioned remarkably by the alterations in impulse propagation. These QRS complex patterns in LVH could be potentially recognized for predicting ventricular arrhythmia and for monitoring the effect of therapy.
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Affiliation(s)
- Ljuba Bacharova
- International Laser Center, 841 04 Bratislava, Slovakia
- Institute of Pathophysiology, Medical School, Comenius University, 841 04 Bratislava, Slovakia
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Egbe AC, Miranda WR, Mehra N, Ammash NM, Missula VR, Madhavan M, Deshmukh AJ, Farouk Abdelsamid M, Kothapalli S, Connolly HM. Role of QRS Fragmentation for Risk Stratification in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 7:e010274. [PMID: 30561260 PMCID: PMC6405623 DOI: 10.1161/jaha.118.010274] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with tetralogy of Fallot (TOF) remain at risk for cardiovascular events despite successful repair. Some of the current risk stratification tools require advanced imaging and invasive studies, and hence are difficult to apply to routine patient care. A recent study showed that QRS fragmentation (QRS‐f) is predictive of mortality in patients with TOF. The current study aims to validate this result by assessing whether severity of QRS‐f could predict all‐cause mortality in a different TOF population. Methods and Results The authors reviewed the Mayo Adult Congenital Heart Disease database for patients with TOF who had ECG from 1990–2017. QRS‐f was defined as notches in QRS complex in ≥2 contiguous leads on ECG, not related to bundle branch block, and classified as none, mild (≤3 leads), moderate (4 leads), or severe (≥5 leads). Of 465 patients (age 37±14 years) in the study, QRS‐f was present in 161 (35%): mild (n=43, 9%), moderate (n=77, 17%), and severe (n=41, 9%). There were 55 deaths (12%) during 13.6±8.2 years of follow‐up. Severity of QRS‐f remained an independent predictor of all‐cause mortality after adjustment for other ECG parameters, patient demographics, and atrial and ventricular arrhythmia (hazard ratio, 1.74 per class; 95% confidence interval, 1.08–2.93 [P=0.041]). Conclusions The presence of severe QRS‐f may be used as complementary data to the usual clinical indices to determine whether interventions such as invasive electrophysiology study should be performed in patients with nonsustained ventricular tachycardia or to proceed with pulmonary valve replacement in patients with severe pulmonary regurgitation with ventricular volumes below the guideline‐directed threshold for intervention.
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Affiliation(s)
- Alexander C Egbe
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Nandini Mehra
- 2 Department of Internal Medicine Mayo Clinic Rochester MN
| | - Naser M Ammash
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | - Malini Madhavan
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | | | - Heidi M Connolly
- 1 Department of Cardiovascular Medicine Mayo Clinic Rochester MN
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Tetralogy of Fallot: risk stratification is straightforward. Or is it? Curr Opin Cardiol 2019; 35:63-69. [PMID: 31574004 DOI: 10.1097/hco.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tetralogy of Fallot (TOF) carries a long-term risk of arrhythmias and sudden death after surgical repair. Risk stratification is still less accurate than desired. RECENT FINDINGS Several factors have been studied as risk predictors for ventricular arrhythmias and sudden death. Clinical parameters include age at surgery, time since repair, types of previous surgeries, and symptoms such as syncope and palpitations. Electrocardiographic parameters that have been studied include QRS interval, ventricular arrhythmias assessed with Holter monitors, signal averaged ECG, QRS fragmentation, QRS vector magnitude, and microvolt T-wave alternans. Exercising testing has been shown to have prognostic significance. Ventricular function assessment with imaging studies including echocardiography and magnetic resonance imaging (MRI) plays a significant role. Invasive hemodynamic and electrophysiologic studies, in addition to assessment for inducible tachycardia, can provide information regarding the electroanatomic substrate of VT. SUMMARY Risk stratification for TOF has improved over the last years with several clinical, electrocardiographic, imaging, and invasive electrophysiologic findings showing promise, but there still a lack of uniformity in approach between various investigators and reproducibility of findings is difficult in larger populations. With use of a combination of factors, a more informed decision can be made.
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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.
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Egbe AC, Vallabhajosyula S, Vojjini R, Banala K, Najam M, Faizee F, Khalil F, Ullah MW, Deshmukh AJ. Prevalence and in-hospital mortality during arrhythmia-related admissions in adults with tetralogy of Fallot. Int J Cardiol 2019; 297:49-54. [PMID: 31604657 DOI: 10.1016/j.ijcard.2019.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/18/2019] [Accepted: 09/04/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although outcomes of arrhythmia diagnosis have been described in ambulatory tetralogy of Fallot (TOF) patients, these have not been studied in hospitalized patients. The purpose of this study was to determine the prevalence and in-hospital mortality due to arrhythmias in TOF patients based on a review of the National Inpatient Sample database. METHODS Admissions in adult TOF patients (2000-2014) were categorized as arrhythmia-related admission (ARA) or non-arrhythmia-related admission (NRA) based on arrhythmia diagnostic codes. RESULTS Of 18,353 admissions, 5071 (27.6%) were ARA. The most common arrhythmias were atrial fibrillation (15.5%), atrial flutter (8.4%) and ventricular tachycardia (8.2%), and the prevalence of overall ARA as well as specific arrhythmia types increased over time. In-hospital mortality for ARA was 5.4%, and decreased over time. Arrhythmia diagnosis was an independent predictor of in-hospital mortality (odds ratio [OR] 1.63, 1.34-2.01, p = 0.001). Similarly, atrial fibrillation (OR 1.49, 1.18-1.89, p = 0.001) and ventricular tachycardia (OR: 2.01, 1.55-2.98, p = 0.001) were independent predictors of in-hospital mortality. Compared to small bed-size hospital, ARA in large hospital bed-size hospital was associated with a lower in-hospital mortality (OR 0.71, 0.53-0.96, p = 0.03). CONCLUSION Atrial fibrillation was the most common arrhythmia in hospitalized TOF patients, and arrhythmia diagnosis (specifically atrial fibrillation and ventricular tachycardia) was an independent predictor of in-hospital mortality, while admission to a large bed-size hospital was associated with a lower risk of in-hospital mortality. Further studies are required to determine if a more proactive approach to arrhythmia management in the ambulatory TOF population will reduce hospitalizations and mortality.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America.
| | | | - Rahul Vojjini
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Keerthana Banala
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Maria Najam
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Faizan Faizee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Fouad Khalil
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Muhammad Wajih Ullah
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, United States of America
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Egbe AC, Kothapalli S, Borlaug BA, Ammash NM, Najam M, Bajwa N, Tarek K, Mathew J, Connolly HM. Mechanism and Risk Factors for Death in Adults With Tetralogy of Fallot. Am J Cardiol 2019; 124:803-807. [PMID: 31272701 DOI: 10.1016/j.amjcard.2019.05.048] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/10/2019] [Accepted: 05/29/2019] [Indexed: 11/26/2022]
Abstract
One of the goals of lifelong care in adults with tetralogy of Fallot (TOF) is early identification and treatment of patients at high risk for adverse events. Clinical risk stratification tools are critical for achieving this goal. We reviewed the Mayo Adult Congenital Heart Disease database and identified 465 TOF patients (age 37 ± 14 years, men 223 [48%]) seen at Mayo Clinic Rochester between 1990 and 2017. The aim was to determine the risk factors for death and/or heart transplant through a comprehensive analysis of 8 groups of variables (demographics, co-morbidities, medications, heart rhythm, echocardiography, cardiac magnetic resonance imaging, cardiac catheterization, and cardiopulmonary exercise test data) using univariable and multivariable Cox proportional hazard models. The end point of death and/or transplant occurred in 57 (12%) patients during a follow-up of 13.6 ± 8.2 years, yielding an event rate of 0.9% per year. Independent risk factors were age >42 years, atrial fibrillation, ≥moderate QRS fragmentation, left ventricular ejection fraction <50%, right ventricular end-diastolic pressure >16 mm Hg, and left ventricle end-diastolic pressure >16 mm Hg. There is nearly a twofold increase in the risk of death and/or transplant per unit increase in number of risk factors (hazard ratio 1.92, 95% confidence interval 1.62 to 2.27, p <0.001). In conclusion, the current study provides risk stratification indices based on a comprehensive risk model of all clinical variables in an unselected TOF population. Further studies are required to determine whether interventions targeted at modifying these risk factors will alter the annual event rate.
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van der Ven JP, van den Bosch E, Bogers AJ, Helbing WA. Current outcomes and treatment of tetralogy of Fallot. F1000Res 2019; 8:F1000 Faculty Rev-1530. [PMID: 31508203 PMCID: PMC6719677 DOI: 10.12688/f1000research.17174.1] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2019] [Indexed: 01/08/2023] Open
Abstract
Tetralogy of Fallot (ToF) is the most common type of cyanotic congenital heart disease. Since the first surgical repair in 1954, treatment has continuously improved. The treatment strategies currently used in the treatment of ToF result in excellent long-term survival (30 year survival ranges from 68.5% to 90.5%). However, residual problems such as right ventricular outflow tract obstruction, pulmonary regurgitation, and (ventricular) arrhythmia are common and often require re-interventions. Right ventricular dysfunction can be seen following longstanding pulmonary regurgitation and/or stenosis. Performing pulmonary valve replacement or relief of pulmonary stenosis before irreversible right ventricular dysfunction occurs is important, but determining the optimal timing of pulmonary valve replacement is challenging for several reasons. The biological mechanisms underlying dysfunction of the right ventricle as seen in longstanding pulmonary regurgitation are poorly understood. Different methods of assessing the right ventricle are used to predict impending dysfunction. The atrioventricular, ventriculo-arterial and interventricular interactions of the right ventricle play an important role in right ventricle performance, but are not fully elucidated. In this review we present a brief overview of the history of ToF, describe the treatment strategies currently used, and outline the long-term survival, residual lesions, and re-interventions following repair. We discuss important remaining challenges and present the current state of the art regarding these challenges.
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Affiliation(s)
- Jelle P.G. van der Ven
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Eva van den Bosch
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Ad J.C.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Cardiology, Radboud UMC - Amalia Children's Hospital, Nijmegen, The Netherlands
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Abstract
BACKGROUND There are limited outcome data in adults with tetralogy of Fallot and pulmonary atresia. The purpose of this study was to describe re-operations and all-cause mortality in adults with tetralogy of Fallot and pulmonary atresia. METHODS Retrospective review of adults with repaired tetralogy of Fallot and pulmonary atresia who received care at the Mayo Adult Congenital Heart Disease Clinic, 1990-2016. All-cause mortality was calculated as events per 100 patient-years from the time of first presentation to the Adult Congenital Heart Disease Clinic. RESULTS Of the 221 patients, the age at initial tetralogy of Fallot repair was 6 (5-13) years, and the age at first presentation to the clinic was 27 - 8 years. All patients had at least one right ventricular to pulmonary artery conduit re-operation. There were 31 deaths (14%) at mean age of 41 - 14 years. The causes of death were end-stage heart failure (n = 17), sudden cardiac death (n=9), post-operative death after cardiac surgery (n = 2), sepsis with multi-system organ failure (n = 2), and unknown (n = 1). All-cause mortality rate was 1.7 per 100 patient-years. The risk factors for all-cause mortality were older age (>12 years) at the time of repair (hazard ratio 1.41, 95 confidence interval 1.06-2.02, p = 0.033), non-sustained ventricular tachycardia (hazard ratio 1.36, 95 confidence interval 1.17-2.47, p = 0.015), and left ventricular ejection fraction <50% (hazard ratio 1.39, 95 confidence interval 1.08-2.31, p = 0.031). CONCLUSION Based on a review of 221 adults with repaired tetralogy of Fallot and pulmonary atresia, all patients had re-operations and all-cause mortality rate was 1.7 events per 100 patient-years. The current study provides important outcomes data for risk stratification in adults with tetralogy of Fallot and pulmonary atresia.
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Elevated non-invasive liver fibrosis markers and risk of liver carcinoma in adult patients after repair of tetralogy of Fallot. Int J Cardiol 2019; 287:121-126. [DOI: 10.1016/j.ijcard.2019.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/09/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022]
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