QRS Prolongation is Associated With Inducible Ventricular Tachycardia After Repair of Tetralogy of Fallot

doi:10.1016/S0002-9149(97)00311-1

The American Journal of Cardiology

Volume 80, Issue 2, 15 July 1997, Pages 160-163

https://doi.org/10.1016/S0002-9149(97)00311-1 Get rights and content

Abstract

Prolonged QRS duration on the electrocardiogram has been found to predict adverse arrhythmic events in patients late after repair of tetralogy of Fallot. Whether QRS duration can also predict inducible ventricular tachycardia (VT) at electrophysiologic study is unknown. Between 1984 and 1995 we studied 135 survivors of tetralogy of Fallot surgery whose age at surgery was 34 days to 37 years (3.7 ± 3.9, median 2.5) and age at electrophysiologic study was 1.4 to 43 years (9.7 ± 8.2, median 6.7). QRS duration was 80 to 240 ms (137 ± 29) and ≥180 ms in 9 patients. Sustained VT was induced in 22 patients (monomorphic in 17). Induced sustained monomorphic VT was related to QRS duration, right ventricular dimension, H-V interval, and presence of symptoms. QRS duration was also related to induced sustained monomorphic VT by multivariate analysis. QRS duration ≥180 ms was 35% sensitive and 97% specific for induced sustained monomorphic VT. QRS duration was related to induced sustained monomorphic VT even when only asymptomatic patients were analyzed. A QRS duration ≥180 ms was 100% sensitive and 96% specific for detecting clinical VT. Prolonged QRS duration on the electrocardiogram is associated with induced sustained monomorphic VT on electrophysiologic study. The finding of prolonged QRS duration should suggest the need for further testing to determine the risk of adverse arrhythmic events in patients after repair of tetralogy of Fallot, even if they are asymptomatic.

Section snippets

Patients

Between January 1984 and the end of 1995, 135 unselected patients (81 men and 54 women) with repaired tetralogy of Fallot underwent evaluation (including electrophysiologic studies) at our institution. Their age at surgery was 34 days to 37 years (mean ± SD 3.7 ± 3.9 years, median 2.5). Of the 135, 85 underwent operation at our institution and the rest, elsewhere. Cardiac evaluation included electrocardiogram, echocardiography, cardiac catheterization and electrophysiologic study. Their ages at

Results

All but 1 patient had undergone transventricular repair of tetralogy of Fallot. A transannular patch was used in 56 (41%), a right ventricular outflow patch in 36 (27%), a valved conduit or homograft between right ventricle and pulmonary trunk in 23 patients (17%), and none of the above techniques in the other 20. Pulmonary artery reconstruction was performed in 32 (24%). Before repair, 46 patients (34%) had undergone palliative operations. Reoperations were performed in 13 (10%) and consisted

Discussion

Sudden death is a major concern after repair of congenital heart disease. Tetralogy of Fallot has long been considered a benchmark lesion in this regard. The terminal event causing sudden death is presumably ventricular arrhythmia.1, 2, 3, 4, 5 Gatzoulis et al[6] recently suggested that QRS prolongation can predict ventricular arrhythmia and sudden death. They concluded that “the use of electrophysiologic study in this group (with prolonged QRS duration) may be able to further identify a

Acknowledgements

We wish to thank Xiaobu Ye for statistical help and Barbara Roberts for secretarial assistance.

References (17)

J Deanfield et al.
Local abnormalities of right ventricular depolarization after repair of tetralogy of Fallot: a basis for ventricular arrhythmia
Am J Cardiol
(1985)
CI Noh et al.
Clinical and electrophysiological characteristics of ventricular tachycardia in children with normal hearts
Am Heart J
(1990)
LN Horowitz et al.
Electrophysiologic characteristics of sustained ventricular tachycardia occurring after repair of tetralogy of Fallot
Am J Cardiol
(1980)
A Garson et al.
Induction of ventricular tachycardia during electrophysiologic study after repair of tetralogy of Fallot
J Am Coll Cardiol
(1983)
BJ Deal et al.
Electrophysiologic drug testing in symptomatic ventricular arrhythmias after repair of tetralogy of Fallot
Am J Cardiol
(1987)
JS Chandar et al.
Ventricular arrhythmias in postoperative tetralogy of Fallot
Am J Cardiol
(1990)
T Meinertz et al.
Determinants of prognosis in idiopathic dilated cardiomyopathy as determined by programmed electrical stimulation
Am J Cardiol
(1985)
JW Dean et al.
Arrhythmia in heart failure: role of mechanically induced changes in electrophysiology (review)
Lancet
(1989)

There are more references available in the full text version of this article.

Cited by (72)

Relation of Norwood Shunt Type and Frequency of Arrhythmias at 6 Years (from the Single Ventricle Reconstruction Trial)
2022, American Journal of Cardiology
The Norwood procedure with a right ventricular to pulmonary artery shunt (RVPAS) decreases early mortality, but requires a ventriculotomy, possibly increasing risk of ventricular arrhythmias (VAs) compared with the modified Blalock-Taussig shunt (MBTS). The effect of shunt and Fontan type on arrhythmias by 6 years of age in the SVRII (Single Ventricle Reconstruction Extension Study) was assessed. SVRII data collected on 324 patients pre-/post-Fontan and annually at 2 to 6 years included antiarrhythmic medications, electrocardiography (ECG) at Fontan, and Holter/ECG at 6 years. ECGs and Holters were reviewed for morphology, intervals, atrioventricular conduction, and arrhythmias. Isolated VA were seen on 6-year Holter in >50% of both cohorts (MBTS 54% vs RVPAS 60%), whereas nonsustained ventricular tachycardia was rare and observed in RVPAS only (2.7%). First-degree atrioventricular block was more common in RVPAS than MBTS (21% vs 8%, p = 0.01), whereas right bundle branch block, QRS duration, and QTc were similar. Antiarrhythmic medication usage was common in both groups, but most agents also supported ventricular function (e.g., digoxin, carvedilol). Of the 7 patients with death or transplant between 2 and 6 years, none had documented VAs, but compared with transplant-free survivors, they had somewhat longer QRS (106 vs 93 ms, p = 0.05). Atrial tachyarrhythmias varied little between MBTS and RVPAS but did vary by Fontan type (lateral tunnel 41% vs extracardiac conduit 29%). VAs did not vary by Fontan type. In conclusion, at 6-year follow-up, benign VAs were common in the SVRII population. However, despite the potential for increased VAs and sudden death in the RVPAS cohort, these data do not support significant differences or increased risk at 6 years. The findings highlight the need for ongoing surveillance for arrhythmias in the SVR population.
Co-occurrence and phase relationship between alternans of the R wave amplitude (RWAA) and of the T wave (TWA) in ECGs
2020, Computers in Biology and Medicine
Alternans of the T wave in ECG (TWA) has high negative but poor positive predictive value in the prediction of ventricular arrhythmia. Alternans of repolarization duration, i.e. of action potential duration (APD), causes TWA. Prior studies from our group showed that alternans of the maximum rate of depolarization also occurs when APD alternans occurs and the relationship between these two has the potential to affect formation of spatial discord, which may be more arrhythmogenic. Therefore, exploration of the co-occurrence of the alternans of depolarization and repolarization has the potential to improve the prediction. In the present study, we used a mathematical model to show that depolarization alternans appears as alternating amplitude of the R wave in the ECG. We also investigated the link between changes in R wave amplitude and TWA. Results from clinical grade ECGs available in the PhysioNet database show that amplitude of the R wave can change as predicted by our experimental results and the mathematical model. Using TWA as the marker of repolarization alternans and R wave amplitude alternans (RWAA) as the marker of depolarization alternans, we investigated the phase relation between them and observed that, similar to previous results from animals, the phase relation between the two can spontaneously change. That is, alternans of depolarization does co-occur with TWA and the phase relationship between the two is not invariant. These results support further investigation of the use of RWAA as a complementary method to TWA to improve positive predictive value for prediction of ventricular arrhythmia.
Slow Conducting Electroanatomic Isthmuses: An Important Link Between QRS Duration and Ventricular Tachycardia in Tetralogy of Fallot
2018, JACC: Clinical Electrophysiology
This study sought to evaluate the influence of slow conducting anatomic isthmuses (SCAI) as dominant ventricular tachycardia (VT) substrate on QRS duration.
QRS prolongation has been associated with VT in repaired tetralogy of Fallot.
Seventy-eight repaired tetralogy of Fallot patients (age 37 ± 15 years, 52 male, QRS duration 153 ± 29 ms, 67 right bundle branch blocks [RBBB]) underwent programmed stimulation and electroanatomic activation mapping during sinus rhythm. Right ventricular (RV) surface, RV activation pattern, RV activation time, conduction velocity at AI, and remote RV sites were determined.
Twenty-four patients were inducible for VT (VT+); SCAI was present in 22 of 24 VT+ but only in 2 of 54 patients without inducible VT (VT−). Conduction velocity through AI was slower in VT+ patients (median of 0.3 [0.3 to 0.4] vs. 0.7 [0.6 to 0.9] m/s; p < 0.01) but conduction velocity in the remote RV did not differ between groups. In non-RBBB, QRS duration was similar in VT+ patients (n = 6) and VT− patients (n = 5), but RV activation within SCAI exceeded QRS offset in VT+ patients (37 ± 20 ms vs. –5 ± 9 ms, p < 0.01). In RBBB, both QRS duration and RV activation time were longer in VT+ patients (n = 18, 17 of 18 QRS > 150 ms) compared with VT− patients (n = 49, 27 of 49 QRS > 150 ms) (173 ± 22 ms vs. 156 ± 20 ms; p < 0.01; 141 ± 22 ms vs. 129 ± 21 ms; p = 0.04). In VT+ patients, QRS prolongation >150 ms (n = 17) was due to SCAI or blocked isthmus in 15 patients (88%) and 1 (6%). In contrast, in VT− patients, QRS prolongation >150 ms (n = 27) was due to enlarged RV or blocked isthmus in 10 patients (37%) and 8 (30%), but due to SCAI in only 1 (4%). After exclusion of a severely enlarged RV, a QRS duration >150 ms was highly predictive for SCAI/blocked AI (OR: 17; 95% CI: 3.3 to 84; p < 0.01).
A narrow QRS interval does not exclude VT-related SCAI. In the presence of RBBB, SCAI further prolongs QRS duration. QRS duration >150 ms is highly suspicious for SCAI or isthmus block distinguishable by electroanatomic mapping.
Role of right ventricular three-dimensional electroanatomic voltage mapping for arrhythmic risk stratification of patients with corrected tetralogy of Fallot or other congenital heart disease involving the right ventricular outflow tract
2016, International Journal of Cardiology
Citation Excerpt :
The individual predisposition to develop such an adverse remodeling could identify patients at higher risk for VAs and/or right heart failure or may reflect preoperative RV impairment due to abnormal hemodynamics and the time elapsed before definitive corrective surgery. QRS duration, in particular its dynamic prolongation during post-surgical follow-up, has been demonstrated to be a strong marker of arrhythmic risk in TOF [8,10,11]. It has been suggested that electrical remodeling could be a consequence of mechanical remodeling, with wider QRS as an expression of slower and more fragmented electrical conduction across the stretched fibers of a dilated myocardium, constituting the substrate for reentry [8].
The post-surgical history of repaired congenital heart disease (rCHD), in particular tetralogy of Fallot (TOF), is often complicated by sudden death. Electrical myocardial abnormalities could be a substrate for malignant ventricular arrhythmias.
146 patients with TOF or other rCHD involving a subpulmonary right ventricle, considered to be at high arrhythmic risk, underwent right ventricular (RV) electroanatomic voltage mapping (EVM). Maps showed endocardial scars (< 0.5 mV) in all cases, mainly involving the RV outflow tract (n = 141, 96.6%). In 28 cases (19.2%), other areas were involved. Total scar extension, expressed as % of total endocardial area, was significantly higher in patients with QRS ≥ 180 ms [4.5% (± 2.5) vs 2.8% (± 2.4), p = 0.014], left and right ventricular systolic dysfunction [4.5% (± 3.2) vs 2.8% (± 2.3), p = 0.016 and 3.5% (± 3.0) vs 2.6% (± 1.9), p = 0.03, respectively], premature ventricular contractions (PVCs) [3.2% (± 2.6) vs 2.2% (± 1.8), p < 0.05], exercise-induced PVCs [3.8% (± 2.4) vs 2.6% (± 2.2), p = 0.01], previous shunt [4.0% (± 2.7) vs 2.6% (± 2.2), p = 0.01] and reintervention [4.2% (± 3.2) vs 2.6% (± 2.0), p = 0.008]. Scar size also showed a positive correlation with duration of post-surgical follow-up (ρ = 0.01), age at correction (ρ = 0.01) and absolute QRS duration (ρ = 0.05).
Patients with rCHD involving the right ventricle show electrical scars with variable distribution, not necessarily matching with sites of surgical lesions. Scar extension correlates with some of the risk factors for life-threatening arrhythmias in CHD, such as prolonged QRS. Thus EVM could be considered an additional tool in the assessment of risk stratification in this particular population.
PACES/HRS expert consensus statement on the recognition and management of arrhythmias in adult congenital heart disease: Developed in partnership between the Pediatric and Congenital Electrophysiology Society (PACES) and the Heart Rhythm Society (HRS). Endorsed by the governing bodies of PACES, HRS, the American College of Cardiology (ACC), the American Heart Association (AHA), the European Heart Rhythm Association (EHRA), the Canadian Heart Rhythm Society (CHRS), and the International Society for Adult Congenital Heart Disease (ISACHD)
2014, Heart Rhythm
EHRA/HRS/APHRS Expert Consensus on Ventricular Arrhythmias
2014, Heart Rhythm
Citation Excerpt :
Indications for ICD implantation in CHD are largely based on expert consensus. Risk assessment strategies,265–270 descriptions of implantation techniques,271 and current guidelines for ICD implantation in CHD1,6,272,273 are available from other sources and not discussed here. A recent consensus document addresses recognition and management details in greater detail.256,257

View all citing articles on Scopus

View full text

QRS Prolongation is Associated With Inducible Ventricular Tachycardia After Repair of Tetralogy of Fallot

Abstract

Section snippets

Patients

Results

Discussion

Acknowledgements

Am J Cardiol

Am Heart J

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Lancet