QRS Duration During Follow-Up of Tetralogy of Fallot: How Valuable is it? Analysis of ECG Changes in Relation to Pulmonary Valve Implantation

Abstract

Long-term results after tetralogy of Fallot (TOF) repair are determined by the extent of right ventricular remodeling to chronic pulmonary regurgitation entailing progressive RV dysfunction and a risk of developing ventricular arrhythmia. Pulmonary valve replacement (PVR) can alleviate this burden. As a predictor of ventricular arrhythmia, QRS duration remains a strong parameter in this decision. We performed a retrospective analysis of all PVR patients between 2005 and 2018, studying the time evolution of electrocardiographic parameters before and after PVR through linear mixed model analysis. 42 TOF patients underwent PVR. The median timespan between primary repair and PVR was 18 years (IQR 13-30). The indication for PVR was primarily based on the association of exercise intolerance (67%) and significant RV dilation on cMRI (median RVEDVi 161 ml/m 2 IQR 133-181). Median QRS length was 155 ms (IQR 138-164), 4 (10%) patients had a QRS > 180 ms. QRS duration increased significantly before PVR, but barely showed regression after PVR. Changes of QRS duration after PVR were independent of RV dilation. In conclusion, when the decision for PVR in TOF patients is primarily based on RV volume and/or function threshold, QRS duration > 180 ms is rarely observed. In contrast with the significant increase of QRS duration before PVR, QRS length regression appears to be independent of the extent of RV dilation or QRS > 160 ms. Considering that the decision for PVR is based on mechanical RV characteristics, the utility of serial follow-up of QRS duration in contemporary operated TOF patients becomes questionable in absence of clinical arguments for ventricular arrhythmia.

Right ventricular dilatation score: a new assessment to right ventricular dilatation in adult patients with repaired tetralogy of Fallot

“…Multiple studies have shown that QRS duration is closely related to RV dilatation (14). Guidelines from the European Society of Cardiology suggest that QRS duration >180mms be used as an indication of PVR (14,17). However, in our research cohort, there was no signi cant difference between groups in QRS duration, even in the RV moderate-severe dilatation group, the median QRS duration was still less than 180mms.…”

“…Cardiac electrophysiology is an important evaluation method for patients with rTOF, and the presence of persistent arrhythmias before surgery often indicates a poor prognosis (14-16). Multiple studies have shown that QRS duration is closely related to RV dilatation (14). Guidelines from the European Society of Cardiology suggest that QRS duration >180mms be used as an indication of PVR (14,17).…”

Outcomes of Transcatheter Pulmonary Valve Replacement and Surgical Pulmonary Valve Replacement: A Cohort Analysis

“…The right ventricular end-diastolic volume index was greater in the SPVR group (184 mL/m 2 [163-230]) than in the TPVR group (165 mL/m 2 [136-190]; P ¼ .001). The maximum PV landing zone diameter measured by balloon sizing (Figure 1) was 24 mm (20-26.5) in the TPVR group and 30 mm (26)(27)(28)(29)(30)(31)(32)(33) in the SPVR group (P < .001) (Table 2). Excluding patients with RVOT conduit, the median size of the PV landing zone in patients with RVOT was 26 mm (24-28) in the 43 patients who underwent TPVR and 31 mm (28)(29)(30)(31)(32)(33)(34) in the 101 patients who underwent SPVR (P < 0.001) (Table 2).…”

“…However, this was not significant in the immediate postoperative period. QRS duration and cardiac MRI findings are correlated with postoperative patients with TOF, [25][26][27] and these arrhythmias can predict survival. [2][3][4]28 Therefore, we assessed the QRS duration as a surrogate variable for RV dilatation.…”

Inherited and Acquired Rhythm Disturbances in Sick Sinus Syndrome, Brugada Syndrome, and Atrial Fibrillation: Lessons from Preclinical Modeling

“…Congenital diseases may eventually manifest during adulthood in response to specific stresses, remaining undiscovered until a dramatic or fatal episode occurs, even in agonistic athletes routinely submitted to ECG to practice [102][103][104][105][106][107][108][109][110][111]. Acquired rhythm pathologies might be induced by several causes, among which drug cardiotoxicity, cardiomyopathies, myocarditis or systemic infections, valve diseases, and interventional/surgical maldeployment of cardiac valve replacements [112][113][114][115][116][117][118][119][120][121][122][123][124][125][126][127][128].…”