Objectives 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). Background 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. Methods 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. Results 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 5ms following PVR (p = 0.0001). Increased age at PVR, QRS ≥ 180ms 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). Conclusions Adults with repaired ToF experience a reduction in QRS duration post-PVR that correlates with the change of the RV size. Patients with QRS ≥ 180ms 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.
Background: Tetralogy of Fallot (ToF) patients face complications such as heart failure and ventricular arrhythmias (VA) after early repair which may be mitigated by pulmonary valve replacement (PVR). Prior studies have shown significant decreases in QRS duration and right ventricular (RV) size following PVR. We aimed to determine whether QRS duration reduction independently identifies patients at lower risk of VA and/or correlates with a decrease of RV size on cardiac magnetic resonance imaging (CMR) with long-term follow-up. Methods: We retrospectively identified patients ≥18 years old with repaired ToF who underwent surgical or transcatheter PVR, respectively, at our tertiary care center. Demographics, imaging, and ECGs (pre-PVR, 30 days to 1-year post-PVR, and closest to follow up CMR) were collected. Patients with ventricularly paced rhythm were excluded. The composite primary outcome was defined as sustained VT, ICD shock for sustained VT or inducible VT on EP study. Results: During the study period, 85 patients were included (median follow-up 3.6 years; median age 34 years; 51% females, 68% surgical PVR and median LVEF 56%). The primary outcome was observed in 8 (9.6%) patients. QRS duration decreased by 5 ms (pre-PVR mean 154±28 ms to 149±28ms post-PVR; p=0.0001). Increased age at PVR (OR 1.1 per year), QRS≥180ms post-PVR, no reduction in QRS after PVR (ΔQRS ≤ 0ms), and a history of VT were significantly associated with the composite outcome. (Table) The change in QRS was linearly correlated with the change in RVEDVi (R = 0.66; p=0.002). Conclusion: In conclusion, adults with repaired ToF experience a reduction in QRS duration post-PVR. This change correlates with the change in the RV size post-operatively. A QRS ≥180ms post-PVR, no reduction in QRS, increased age at repair, and a history of VT independently predict the occurrence of VT post-PVR. Patients with these risk factors may warrant closer monitoring and/or ICD consideration.
Background and Hypothesis: Pulmonary valve replacement (PVR) is one of the most commonly performed procedures for patients with congenital heart disease. Transcatheter-based PVR (TPVR) approaches have emerged as alternatives to surgical pulmonary valve replacement (SPVR), but few studies have directly compared clinical outcomes between the two interventions. Further characterization of performance between the two valve procedures may inform clinical decision-making. Project Methods: Using institutional databases, we identified patients aged ≥ 9 years who underwent either a TPVR or SPVR at Riley Hospital for Children between January 2009 and June 2020. Exclusions were made for previous endocarditis diagnosis, <1 year follow-up, and concomitant left heart procedures. Valve dysfunction was defined as ≥ moderate regurgitation or gradient ≥ 40 mmHg. Results: 94 (TPVR, n=52; SPVR, n=42) patients met inclusion criteria. Average follow-up for SPVR and TPVR patients was 5.1(2.0,6.7) and 2.9(1.6,4.8) years, respectively (p=0.007). The SPVR cohort was younger, had lower BMI, and underwent more prior sternotomies. Hospital length of stay was shorter after TPVR (1.0 day vs. 5.0 days, p<0.001). Despite being younger, BSA-indexed valve size was larger in the SPVR cohort (14.7 mm/m2 vs 12.9 mm/m2, p<0.001). Short-term mortality (0% vs 2%, p=0.36), endocarditis (0% vs 6%, p=0.11), and reintervention (12% vs 8%, p=0.49) did not differ between groups. Intermediate-term valve dysfunction/failure was greater in SPVR patients (29% vs 12%, p=0.04) with time to dysfunction 809(421,1565) and 1184(181,1627) days for SPVR and TPVR, respectively. Valve implantation failure due to pre-stent migration occurred in 4% of TPVR cases; one required surgical intervention. Conclusion and Potential Impact: In patients undergoing PVR at our institution, rates of mortality and infective endocarditis are similar between interventions. Intermediate-term valve dysfunction/failure was greater in SPVR cohort, but length of follow-up was significantly longer in these patients. Reintervention rates were similar between procedures.
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