Systematic Electrophysiological Study Prior to Pulmonary Valve Replacement in Tetralogy of Fallot: A Prospective Multicenter Study

BACKGROUND

Ventricular arrhythmias and sudden death are recognized complications in tetralogy of Fallot. Electrophysiological studies (EPS) before pulmonary valve replacement (PVR), the most common reintervention in tetralogy of Fallot, could potentially inform therapy to improve arrhythmic outcomes.

METHODS

A prospective multicenter study was conducted to systematically assess EPS with programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR from January 2020 to December 2021. A standardized stimulation protocol was used across all centers.

RESULTS

A total of 120 patients were enrolled, mean age 39.2±14.5 years, 53.3% males. Sustained ventricular tachycardia was induced in 27 (22.5%) patients. When identifiable, the critical isthmus most commonly implicated (ie, in 90.0%) was between the ventricular septal defect patch and pulmonary annulus. Factors independently associated with inducible ventricular tachycardia were history of atrial arrhythmia (OR, 8.56 [95% CI, 2.43-34.73]) and pulmonary annulus diameter >26 mm (OR, 5.05 [95% CI, 1.47-21.69]). The EPS led to a substantial change in management in 23 (19.2%) cases: 18 (15.0%) had catheter ablation, 3 (2.5%) surgical cryoablation during PVR, and 9 (7.5%) defibrillator implantation. Repeat EPS 5.1 (4.8-6.2) months after PVR was negative in 8 of 9 (88.9%) patients. No patient experienced a sustained ventricular arrhythmia during 13 (6.1-20.1) months of follow-up.

CONCLUSIONS

Systematically performing programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR yields a high rate of inducible ventricular tachycardia and carries the potential to alter management. It remains to be determined whether a standardized treatment approach based on the results of EPS will translate into improved outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04205461.

Pulmonary Atresia With Ventriculocoronary Arterial Connections and a Large Conoventricular Septal Defect

Ventriculocoronary arterial connections are typically found in patients with pulmonary atresia with an intact ventricular septum. This report describes a case of ventriculocoronary arterial connections in a patient with pulmonary atresia with a ventricular septal defect. Our case supports recent data suggesting a primary coronary artery developmental anomaly in pulmonary atresia. (Level of Difficulty: Advanced.)

[Selective tricuspid annuloplasty without prosthetic support]

Two techniques of plastic surgery are currently used to treat tricuspid insufficiency: a prosthetic reductor or a continuous running suture. In the technique advocated here a double continuous suture is inserted into the tricuspid annulus, one running from the antero-septal to the antero-external commissures and the other, from the postero-septal to the antero-external commissures. When these two sutures are tied separately, the circumferences of the two parts of the annulus, which are diversely dilated, can be reduced. The authors have used this technique in 141 patients and a Carpentier's annulus in 41 patients. Perioperative mortality and 5-year survival were the same in both series, but the incidence of postoperative atrioventricular block was much lower in the first one. Another advantage of the double continuous suture technique is that foreign material is reduced to a minimum.