Download ePapyrus PDF Document

MAIN TOPIC REVIEWS
June Huh, MD
Department of Pediatrics, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
Arrhythmias in postoperative congenital heart diseses
ABSTRACT
Congenital heart diseases (CHD) are commonly associated with early- and late-onset arrhythmias after
hemodynamic and/or anatomical surgical treatment. In order to diagnose postoperative arrhythmias in CHD,
an understanding of the complex anatomy, predisposing factors and hemodynamic abnormalities is reguired.
Substrates for arrhythmias in postoperative arrhythmias are related to hemodynamic abnormalities and
anatomical lesions caused by surgery as well as by underlying congenital cardiac defects. According to the
cardiac conduction components, postoperative arrhythmias in CHD can be classified into five groups;
arrhythmias related to sinus node function,
related to atrioventricular node function,
arrhythmias related to intraatrial conduction,
arrhythmias
arrhythmias related to ventricular conduction abnormalities,
mixed. The management of arrhythmias in CHD should be integrated with the care of the underlying heart
defects and hemodynamic abnormalities.
Key words:
congenital heart defects
cardiac arrhythmia
Received: August 30, 2010
Revision Received: November 11, 2010
Accepted:
Correspondence: June Huh, MD, Division of Pediatric Cardiology,
Department of Pediatrics,Grown-up Congenital Heart Clinic, Cardiac and
Vascular Center, Samsung Medical Center, Sungkyunkwan University
School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, Korea
Tel: 82-2-3410-3539, Fax: 82-2-3410-0043
E-mail: [email protected], or [email protected]
34
Journal of Cardiac Arrhythmia
surgery
risk factors
VOL.11 NO.4
35
MAIN TOPIC REVIEWS
MAIN TOPIC REVIEWS
36
Journal of Cardiac Arrhythmia
MAIN TOPIC REVIEWS
>
Symptomatic supraventricular arrhythmias
in congenital heart disease
Medication
1) Unrepaired CHD Not need repir
ASD small
2) Unrepaired CHD Need repair
ASD large
Ebstein A
3) Surgical atrial scar (+)
Any CHD
4) Accessory pathyway twin AV node
SAN dysfunction
5) Correctable hemodynamic factor (+)
Ebstein A
cc-TGA
Isomerism
Device closure
EPS±RFCA
EPS±
RFCA±
PPM
Surgery±concomitant
arrhythmia op.
±PPM
if need
AVV
Dysfunction
Figure 1. Approach to symptomatic supraventricular arrhythmias in congenital heart disease.
AV; atrioventricular, AVV; atrioventricular valves, cc-TGA; congenitally corrected TGA, CHD; congenital heart disease, Ebstein A; Ebstein's
anomaly, EPS; electrophysiology study, op; operation, PPM; permanent pacemaker, RFCA; radiofrequency catheter ablation, SAN;
sinoatrial node
VOL.11 NO.4
37
MAIN TOPIC REVIEWS
Symptomatic ventricular arrhythmias
in congenital heart disease
VT from pulmonary ventricle
VT
from systemic ventricle
or single ventricle
- Wide QRS >180 ms
- Severe dilated RV
- Ventricular scar (+)
- RV dysfunction
- Ventricle function
- Ventricular scar (+)
EPS/RFCA
- Fragmented QRS
- Hemodynamics of VT
High LVEDP
VT induction (+)
Nonsustained VT
Prior to surgery for PVR
Stable VT
Unstable VT
Activation mapping
Entrainment
Pace mapping
3D mapping
Successful RFCA? ICD? CRT? Surgery?
Figure 2. Approach to symptomatic ventricular arrhythmias in congenital heart disease.
ICD; implantable cardioverter defibrillator, LVEDP; left ventricle end-diastolic preesure, PVR; pulmonary valve replacement,
RFCA; radiofrequency catheter ablation, RV; right ventricle, VT; ventricular tachycardia
Figure 3. MRI showed dilatation RV and RA.
RA; right atrium, RV; right ventricle
38
Journal of Cardiac Arrhythmia
MAIN TOPIC REVIEWS
Figure 4. ECG showed atrial flutter with RBB QRS morphology.
ECG; electrocardiogram, RBB; right bundle branch
Figure 5. Isthmus dependent atrial flutter was noted during EPS.
EPS; electro-physiological study
VOL.11 NO.4
39
MAIN TOPIC REVIEWS
Figure 6. Ventricular tachycardia was induced with LBBB morphology.
LBBB; left bundle branch block
Figure 7. 3D mapping confirmed that ventricular tachycardia had macroreentry around RVOT scar.
RVOT; right ventricular outflow tract
40
Journal of Cardiac Arrhythmia
1. van der Velde ET, Vriend JW, Mannens MM, Uiterwaal CS, Brand
R,Mulder BJ. CONCOR, an initiative towards a national registry
and DNA-bank of patients with congenital heart disease in the
Netherlands: rationale, design, and first results. Eur J Epidemiol.
2005;20:549-557.
2. Deanfield J, Camm J, Macartney F, Cartwright T, Douglas J, Drew
J, de Leval M, Stark J. Arrhythmia and late mortality after
Mustard and Senning operation for transposition of the great
arteries: An eight-year prospective study. J Thorac Cardiovasc
Surg. 1988;96:569-576.
3. Vetter VL, Tanner CS, Horowitz LN. Electrophysiologic
consequences of the Mustard repair of d-transposition of the
great arteries. J Am Coll Cardiol. 1987;10:1265-1273.
4. Gewillig M, Wyse RK, de Leval MR, Deanfield JE. Early and late
arrhythmias after the Fontan operation: Predisposing factors and
clinical consequences. Br Heart J. 1992;37:72-79.
5. Kurer CC, Tanner CS, Norwood WI, Vetter VL. Perioperative
arrhythmias after Fontan repair. Circulation. 1990;82:IV190IV194.
6. Kavey RE, Gaum WE, Byrum CJ, Smith FC, Kveselis DA. Loss of
sinus rhythm after total cavopulmonary connection. Circulation.
1995;92:II304-II308.
7. Gatzoulis MA, Freeman MA, Siu SC, Webb GD, Harris L. Atrial
arrhythmia after surgical closure of atrial septal defects in adults.
N Engl J Med. 1999;340:839-846.
8. Mantovan R, Gatzoulis MA, Pedrocco A, Ius P, Cavallini C, De
Leo A, Zecchel R, Calzolari V, Valfre C, Stritoni P.
Supraventricular arrhythmia before and after surgical closure of
atrial septal defects: spectrum, prognosis and management.
Europace. 2003;5:133-138.
9. Silversides CK, Siu SC, McLaughlin PR, Haberer KL, Webb GD,
Benson L, Harris L. Symptomatic atrial arrhythmias and
transcatheter closure of atrial septal defects in adult patients.
Heart. 2004;90:1194-1198.
10. Gewillig M, Cullen S, Mertens B, Lesaffre E, Deanfield J. Risk
factors for arrhythmia and death after Mustard operation for
simple transposition of the great arteries. Circulation .
1991;84:III187-III192.
11. Balaji S, Gewillig M, Bull C, de Leval MR, Deanfield
JE.Arrhythmias after the Fontan procedure: Comparison of total
cavopulmonary connection and atriopulmonary connection.
Circulation. 1991;84:III162-III167.
12. Peters NS, Somerville J. Arrhythmias a after the Fontan
procedure. Br Heart J. 1992; 68:199-204.
13. Cecchin F, Johnsrude CL, Perry JC, Friedman RA. Effect of age
and surgical technique on symptomatic arrhythmias after the
Fontan procedure. Am J Cardiol. 1995;76:386-391.
14. Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM,
Warnes CA, Li Z, Hodge DO, Driscoll DJ. Functional status after
MAIN TOPIC REVIEWS
References
operation for Ebstein anomaly: the Mayo Clinic experience. J Am
Coll Cardiol. 2008;52:460-466.
15. Watson H. Natural history of Ebstein s anomaly of tricuspid
valve in childhood and adolescence. An international cooperative study of 505 cases. Br Heart J. 1974;36:417-427.
16. Murphy JG, Gersh BJ, Mair DD, Fuster V, McGoon MD, Ilstrup
DM, McGoon DC, Kirklin JW, Danielson GK. Long-term outcome
in patients undergoing surgical repair of tetralogy of Fallot. N
Engl J Med. 1993;329:593-599.
17. Nollert G, Fischlein T, Bouterwek S, Bohmer C, Klinner W,
Reichart B. Long-term survival in patients with repair of
tetralogy of Fallot: 36-year follow-up of 490 survivors of the first
year after surgical repair. J Am Coll Cardiol. 1997;30:13741383.
18. Silka MJ, Hardy BG, Menashe VD, Morris CD. A populationbased prospective evaluation of risk of sudden cardiac death
after operation for common congenital heart defects. J Am Coll
Cardiol. 1998;32:245-251.
19. N rgaard MA, Lauridsen P, Helvind M, Pettersson G. Twentytothirty- seven-year follow-up after repair for Tetralogy of Fallot.
Eur J Cardiothorac Surg. 1999;16:125-130.
20. Therrien J, Webb G. Clinical update on adults with congenital
heart disease. Lancet. 2003;362:1305-1313.
21. Chowdhury UK, Sathia S, Ray R, Singh R, Pradeep KK,
Venugopal P. Histopathology of the right ventricular outflow
tract and its relationship to clinical outcomes and arrhythmias in
patients with tetralogy of Fallot. J Thorac Cardiovasc Surg.
2006;132:270-277.
22. Therrien J, Siu SC, Harris L, Dore A, Niwa K, Janousek J,
Williams WG, Webb G, Gatzoulis MA. Impact of pulmonary
valve replacement on arrhythmia propensity late after repair of
tetralogy of Fallot. Circulation. 2001;103:2489-2494.
23. Harrild DM, Berul CI, Cecchin F, Geva T, Gauvreau K, Pigula F,
Walsh EP. Pulmonary valve replacement in tetralogy of Fallot:
impact on survival and ventricular tachycardia. Circulation.
2009;119:445-451.
24. Durongpisitkul K, Porter CJ, Cetta F, Offord KP, Slezak JM, Puga
FJ, Schaff HV, Danielson GK, Driscoll DJ. Predictors of early- and
late-onset supraventricular tachyarrhythmias after Fontan
operation. Circulation. 1998;98:1099-1107.
25. Gelatt M, Hamilton RM, McCrindle BW, Gow RM, Williams WG,
Trusler GA, Freedom RM. Risk factors for atrial tachyarrhythmias
after the Fontan operation. J Am Coll Cardiol. 1994;24:17351741.
26. Fishberger SB, Wernovsky G, Gentles TL, Gauvreau K, Burnett J,
Mayer JE Jr, Walsh EP. Factors that influence the development
of atrial flutter after the Fontan operation. J Thorac Cardiovasc
Surg. 1997;113:80-86.
27. Sheikh AM, Tang AT, Roman K, Baig K, Mehta R, Morgan J,
Keeton B, Gnanapragasam J, Vettukattil JV, Salmon AP, Monro
JL, Haw MP. The failing Fontan circulation: Successful
conversion of atriopulmonary connections. J Thorac Cardiovasc
Surg. 2004;128:60-66.
VOL.11 NO.4
41
MAIN TOPIC REVIEWS
28. Morales DL, Dibardino DJ, Braud BE, Fenrich AL, Heinle JS,
Vaughn WK, McKenzie ED, Fraser CD Jr. Salvaging the failing
Fontan: Lateral tunnel versus extracardiac conduit. Ann Thorac
Surg. 2005;80:1445-1452.
29. Gatzoulis MA, Balaji S, Webber SA, Siu SC, Hokanson JS, Poile
C, Rosenthal M, Nakazawa M, Moller JH, Gillette PC, Webb GD,
Redington AN. Risk factors for arrhythmia and sudden death
late after repair of tetralogy of Fallot: a multicentre study.
Lancet. 2000;356:975-981.
30. Gatzoulis MA, Till JA, Redington AN. Depolarizationrepolarization inhomogeneity after repair of tetralogy of Fallot.
The substrate for malignant ventricular tachycardia? Circulation.
1997;95:401-404.
31. Gatzoulis MA, Till JA, Somerville J, Redington AN.
Mechanoelectrical interaction in tetralogy of Fallot. QRS
prolongation relates to right ventricular size and predicts
malignant ventricular arrhythmias and sudden death.
Circulation. 1995;92:231-237.
32. Uebing A, Gibson DG, Babu-Narayan SV, Diller GP, Dimopoulos
K, Goktekin O, Spence MS, Andersen K, Henein MY, Gatzoulis
MA, Li W. Right ventricular mechanics and QRS duration in
patients with repaired tetralogy of Fallot: implications of
infundibular disease. Circulation. 2007;116:1532-1539.
33. Stelling JA, Danford DA, Kugler JD, Windle JR, Cheatham JP,
Gumbiner CH, Latson LA, Hofschire PJ. Late potentials and
42
Journal of Cardiac Arrhythmia
inducible ventricular tachycardia in surgically repaired congenital
heart disease. Circulation. 1990;82:1690-1696.
34. Gold MR, Ip JH, Costantini O, Poole JE, McNulty S, Mark DB,
Lee KL, Bardy GH. Role of microvolt T-wave alternans in
assessment of arrhythmia vulnerability among patients with
heart failure and systolic dysfunction: primary results from the Twave alternans sudden cardiac death in heart failure trial
substudy. Circulation. 2008;118:2022-2028.
35. Daliento L, Caneve F, Turrini P, Buja G, Nava A, Milanesi O,
Stellin G, Rizzoli G. Clinical significance of high-frequency, lowamplitude electrocardiographic signals and QT dispersion in
patients operated on for tetralogy of Fallot. Am J Cardiol .
1995;76:408-411.
36. Das MK, Suradi H, Maskoun W, Michael MA, Shen C, Peng J,
Dandamudi G, Mahenthiran J. Fragmented wide QRS on a 12lead ECG: a sign of myocardial scar and poor prognosis. Circ
Arrhythm Electrophysiol. 2008;1:258-268.
37. Morita H, Kusano KF, Miura D, Nagase S, Nakamura K, Morita
ST, Oh T, Zipes DP, Wu J. Fragmented QRS as a marker of
conduction abnormality and a predictor of prognosis of Brugada
syndrome. Circulation. 2008;118:1697-1704.
38. Park SJ, On YK, Kim JS, Kang IS, Lee HJ, Choe YH, Huh J.
Fragmentation of wide QRS complex as a surrogate marker for
surgical scars of TOF patients. The 3rd congress of Asia-pacific
Pediatric Cardiac Society. 2010;280 [abstract].