Exploring the cause of conduction delays in patients with repaired Tetralogy of Fallot

Verzaal, Nienke J; Massé, Stéphane; Downar, Eugene; Nanthakumar, Kumaraswamy; Delhaas, Tammo; Prinzen, Frits W.

doi:10.1093/europace/euaa400

Cited by 8 publications

(4 citation statements)

References 27 publications

(36 reference statements)

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“…RBBB is uncommon prior to primary repair in TOF occurring only in 4% of cases but increases significantly following primary repair to 61% ( p = <0.001) and increases subsequently through the early postoperative period after PVR (89%). Horowitz et al showed that RBBB is related to infundibular resection in rTOF and more recently Verzaal et al showed that the main mechanism is block in the Purkinje system ( 40 , 41 ). Of interest, RBBB increases after PVR, which could be due to the need to excise additional muscle to accommodate the conduit.…”

Section: Discussionmentioning

confidence: 99%

Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair

Bhat,

Malm,

Sjöberg

et al. 2024

Front. Cardiovasc. Med.

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BackgroundECG 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.MethodsWe 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.ResultsTwo 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.ConclusionsPQ 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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Section: Discussionmentioning

confidence: 99%

Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair

Bhat,

Malm,

Sjöberg

et al. 2024

Front. Cardiovasc. Med.

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“… 12 However, local slow conduction at the septal infundibulum between the VSD patch and the pulmonary annulus (SCAI 3) significantly alters the terminal activation of the RV, with a shift in the activation wavefront from the basal lateral peri-tricuspid RV towards the lateral RVOT ( Figure 5 ), provided that there is no normal conducting AI 4. 12 , 13 The latter is observed in only a small group of rTOF patients with a muscular ridge between the VSD patch and the tricuspid annulus, information that is usually available from the surgical reports. In these patients, rapid conduction through AI 4 will compensate for the delay through AI 3 and will result in normal terminal RV activation ( Figure 7A ).…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2023

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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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“…Recent data, though, has demonstrated that the more distal right sided conduction system is relatively intact. (Verzaal et al, 2021).…”

Section: Future Directionsmentioning

confidence: 99%

Conduction system pacing in pediatric and congenital heart disease

et al. 2023

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Conduction system pacing (CSP) has evolved rapidly to become the pacing method of choice for many adults with structurally normal hearts. Studies in this population have repeatedly demonstrated superior hemodynamics and outcomes compared to conventional pacing with the recruitment of the native conduction system. Children and patients with congenital heart disease (CHD) are also likely to benefit from CSP but were excluded from original trials. However, very recent studies have begun to demonstrate the feasibility and efficacy of CSP in these patients, with growing evidence that some outcomes may be superior in comparison to conventional pacing techniques. Concerns regarding the technical challenges and long-term lead parameters of His Bundle Pacing (HBP) have been overcome to many extents with the development of Left Bundle Branch Area Pacing (LBBAP), and both techniques are likely to play an important role in pediatric and CHD pacing in the future. This review aims to assimilate the latest developments in CSP and its application in children and CHD patients.

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Exploring the cause of conduction delays in patients with repaired Tetralogy of Fallot

Cited by 8 publications

References 27 publications

Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair

Longitudinal ECG changes in tetralogy of Fallot and association with surgical repair

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

Conduction system pacing in pediatric and congenital heart disease

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