Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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Practical stepwise approach to rhythm disturbances in congenital heart diseases

  • Huh, June (Department of Pediatrics, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • Received : 2010.05.14
  • Accepted : 2010.05.19
  • Published : 2010.06.15
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Abstract

Patients with congenital heart diseases (CHD) are confronted with early- and late-onset complications, such as conduction disorders, arrhythmias, myocardial dysfunction, altered coronary flow, and ischemia, throughout their lifetime despite successful hemodynamic and/or anatomical correction. Rhythm disturbance is a well-known and increasingly frequent cause of morbidity and mortality in patients with CHD. Predisposing factors to rhythm disturbances include underlying cardiac defects, hemodynamic changes as part of the natural history, surgical repair and related scarring, and residual hemodynamic abnormalities. Acquired factors such as aging, hypertension, diabetes, obesity, and others may also contribute to arrhythmogenesis in CHD. The first step in evaluating arrhythmias in CHD is to understand the complex anatomy and to find predisposing factors and hemodynamic abnormalities. A practical stepwise approach can lead to diagnosis and prompt appropriate interventions. Electrophysiological assessment and management should be done with integrated care of the underlying heart defects and hemodynamic abnormalities. Catheter ablation and arrhythmia surgery have been increasingly applied, showing increasing success rates with technological advancement despite complicated arrhythmia circuits in complex anatomy and the difficulty of access. Correction of residual hemodynamic abnormalities may be critical in the treatment of arrhythmia in patients with CHD.

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References

  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;20:549-57. https://doi.org/10.1007/s10654-005-4264-9
  2. Murphy JG, Gersh BJ, Mair DD, Fuster V, McGoon MD, Ilstrup DM, et al. Long-term outcome in patients undergoing surgical repair of tetralogy of Fallot. N Engl J Med 1993;329:593-9. https://doi.org/10.1056/NEJM199308263290901
  3. 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;340:839-46. https://doi.org/10.1056/NEJM199903183401103
  4. Mantovan R, Gatzoulis MA, Pedrocco A, Ius P, Cavallini C, De Leo A, et al. Supraventricular arrhythmia before and after surgical closure of atrial septal defects: spectrum, prognosis and management. Europace 2003;5:133-8. https://doi.org/10.1053/eupc.2002.0294
  5. Kobayashi J, Yamamoto F, Nakano K, Sasako Y, Kitamura S, Kosakai Y. Maze procedure for atrial fibrillation associated with atrial septal defect. Circulation 1998;98(19 Suppl):II399-402.
  6. Silversides CK, Siu SC, McLaughlin PR, Haberer KL, Webb GD, Benson L, et al. Symptomatic atrial arrhythmias and transcatheter closure of atrial septal defects in adult patients. Heart 2004;90:1194-8. https://doi.org/10.1136/hrt.2003.022475
  7. Zeppenfeld K, Schalij MJ, Bartelings MM, Tedrow UB, Koplan BA, Soejima K, et al. Catheter ablation of ventricular tachycardia after repair of congenital heart disease: electroanatomic identification of the critical right ventricular isthmus. Circulation 2007;116:2241-52. https://doi.org/10.1161/CIRCULATIONAHA.107.723551
  8. Chowdhury UK, Sathia S, Ray R, Singh R, Pradeep KK, Venugopal P. Histopathology of the right ventricular outfl ow tract and its relationship to clinical outcomes and arrhythmias in patients with tetralogy of Fallot. J Thorac Cardiovasc Surg 2006;132:270-7. https://doi.org/10.1016/j.jtcvs.2006.04.001
  9. Gatzoulis MA, Balaji S, Webber SA, Siu SC, Hokanson JS, Poile C, et al. Risk factors for arrhythmia and sudden death late after repair of tetralogy of Fallot: a multicentre study. Lancet 2000;356:975-81. https://doi.org/10.1016/S0140-6736(00)02714-8
  10. Gatzoulis MA, Till JA, Redington AN. Depolarization-repolarization inhomogeneity after repair of tetralogy of Fallot. The substrate for malignant ventricular tachycardia? Circulation 1997;95:401-04. https://doi.org/10.1161/01.CIR.95.2.401
  11. Berul CI, Hill SL, Geggel RL, Hijazi ZM, Marx GR, Rhodes J, et al. Electrocardiographic markers of late sudden death risk in postoperative tetralogy of Fallot children. J Cardiovasc Electrophysiol 1997;8:1349-56. https://doi.org/10.1111/j.1540-8167.1997.tb01031.x
  12. 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;92:231-7. https://doi.org/10.1161/01.CIR.92.2.231
  13. Tateno S, Niwa K, Nakazawa M, Iwamoto M, Yokota M, Nagashima M, Echigo S, et al. Risk factors for arrhythmia and late death in patients with right ventricle to pulmonary artery conduit repair--Japanese multicenter study. Int J Cardiol 2006;106:373-81. https://doi.org/10.1016/j.ijcard.2005.02.030
  14. Uebing A, Gibson DG, Babu-Narayan SV, Diller GP, Dimopoulos K, Goktekin O, et al. Right ventricular mechanics and QRS duration in patients with repaired tetralogy of Fallot: implications of infundibular disease. Circulation 2007;116:1532-9. https://doi.org/10.1161/CIRCULATIONAHA.107.688770
  15. Wijnmaalen AP, Schalij MJ, Bootsma M, Kies P, DE Roos A, Putter H, et al. Patients with scar-related right ventricular tachycardia: determinants of long-term outcome. J Cardiovasc Electrophysiol 2009;20:1119-27. https://doi.org/10.1111/j.1540-8167.2009.01516.x
  16. 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;30:1374-83. https://doi.org/10.1016/S0735-1097(97)00318-5
  17. Silka MJ, Hardy BG, Menashe VD, Morris CD. A population-based prospective evaluation of risk of sudden cardiac death after operation for common congenital heart defects. J Am Coll Cardiol 1998;32:245-51. https://doi.org/10.1016/S0735-1097(98)00187-9
  18. Norgaard MA, Lauridsen P, Helvind M, Pettersson G. Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot. Eur J Cardiothorac Surg 1999;16:125-30. https://doi.org/10.1016/S1010-7940(99)00137-2
  19. Therrien J, Webb G. Clinical update on adults with congenital heart disease. Lancet 2003;362:1305-13. https://doi.org/10.1016/S0140-6736(03)14574-6
  20. Therrien J, Siu SC, Harris L, Dore A, Niwa K, Janousek J, et al. Impact of pulmonary valve replacement on arrhythmia propensity late after repair of tetralogy of Fallot. Circulation 2001;103:2489-94. https://doi.org/10.1161/01.CIR.103.20.2489
  21. Harrild DM, Berul CI, Cecchin F, Geva T, Gauvreau K, Pigula F, et al. Pulmonary valve replacement in tetralogy of Fallot: impact on survival and ventricular tachycardia. Circulation 2009;119:445-51. https://doi.org/10.1161/CIRCULATIONAHA.108.775221
  22. Harrison DA, Siu SC, Hussain F, MacLoghlin CJ, Webb GD, Harris L. Sustained atrial arrhythmias in adults late after repair of tetralogy of Fallot. Am J Cardiol 2001;87:584-8. https://doi.org/10.1016/S0002-9149(00)01435-1
  23. Karamlou T, Silber I, Lao R, McCrindle BW, Harris L, Downar E, et al. Outcomes after late reoperation in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery. Ann Thorac Surg 2006;81:1786-93. https://doi.org/10.1016/j.athoracsur.2005.12.039
  24. Durongpisitkul K, Porter CJ, Cetta F, Offord KP, Slezak JM, Puga FJ, et al. Predictors of early- and late-onset supraventricular tachyarrhythmias after Fontan operation. Circulation 1998;98:1099-107. https://doi.org/10.1161/01.CIR.98.11.1099
  25. Gelatt M, Hamilton RM, McCrindle BW, Gow RM, Williams WG, Trusler GA, et al. Risk factors for atrial tachyarrhythmias after the Fontan operation J Am Coll Cardiol 1994;24:1735-41. https://doi.org/10.1016/0735-1097(94)90181-3
  26. Fishberger SB, Wernovsky G, Gentles TL, Gauvreau K, Burnett J, Mayer JE Jr, et al. Factors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 1997;113:80-6. https://doi.org/10.1016/S0022-5223(97)70402-1
  27. Stamm C, Friehs I, Ho SY, Moran AM, Jonas RA, del Nido PJ. Congenital supravalvar aortic stenosis: a simple lesion? Eur J Cardiothorac Surg 2001;19:195-202. https://doi.org/10.1016/S1010-7940(00)00647-3
  28. Sheikh AM, Tang AT, Roman K, Baig K, Mehta R, Morgan J, et al. The failing Fontan circulation: Successful conversion of atriopulmonary connections. J Thorac Cardiovasc Surg 2004;128:60-6. https://doi.org/10.1016/j.jtcvs.2004.02.011
  29. Morales DL, Dibardino DJ, Braud BE, Fenrich AL, Heinle JS, Vaughn WK, et al. Salvaging the failing Fontan: Lateral tunnel versus extracardiac conduit. Ann Thorac Surg 2005;80:1445-52. https://doi.org/10.1016/j.athoracsur.2005.03.112
  30. Gatzoulis MA, Walters J, McLaughlin PR, Merchant N, Webb GD, Liu P. Late arrhythmia in adults with the mustard procedure for transposition of great arteries: a surrogate marker for right ventricular dysfunction? Heart 2000;84:409-15. https://doi.org/10.1136/heart.84.4.409
  31. Brown ML, Dearani JA, Danielson GK, Cetta F, Connolly HM, Warnes CA, et al. Functional status after operation for Ebstein anomaly: the Mayo Clinic experience. J Am Coll Cardiol 2008;52:460-6. https://doi.org/10.1016/j.jacc.2008.03.064
  32. Watson H. Natural history of Ebstein's anomaly of tricuspid valve in childhood and adolescence. An international co-operative study of 505 cases. Br Heart J 1974;36:417-27. https://doi.org/10.1136/hrt.36.5.417
  33. Overgaard CB, Harrison DA, Siu SC, Williams WG, Webb GD, Harris L. Outcome of previous tricuspid valve operation and arrhythmias in adult patients with congenital heart disease. Ann Thorac Surg 1999;68:2158-63. https://doi.org/10.1016/S0003-4975(99)00854-1
  34. Monro JL, Alexiou C, Salmon AP, Keeton BR. Reoperations and survival after primary repair of congenital heart defects in children. J Thorac Cardiovasc Surg 2003; 26:511-20.
  35. Khairy P, Dore A, Talajic M, Dubuc M, Poirier N, Roy D, et al. Arrhythmias in adult congenital heart disease. Expert Rev Cardiovasc Ther 2006;4:83-95. https://doi.org/10.1586/14779072.4.1.83
  36. Walsh EP. Interventional electrophysiology in patients with congenital heart disease. Circulation 2007;115:3224-34. https://doi.org/10.1161/CIRCULATIONAHA.106.655753
  37. Gittenberger-de Groot AC, Bartelings MM, Deruiter MC, Poelmann RE. Basics of cardiac development for the understanding of congenital heart malformations. Pediatr Res 2005;57:169-76. https://doi.org/10.1203/01.PDR.0000148710.69159.61
  38. Wongcharoen W, Chen YC, Chen YJ, Chen SY, Yeh HI, Lin CI, et al. Aging increases pulmonary veins arrhythmogenesis and susceptibility to calcium regulation agents. Heart Rhythm 2007;4:1338-49. https://doi.org/10.1016/j.hrthm.2007.06.023
  39. Aronow WS. Heart disease and aging. Med Clin North Am 2006;90:849-62. https://doi.org/10.1016/j.mcna.2006.05.009
  40. Casaclang-Verzosa G, Gersh BJ, Tsang TS. Structural and functional remodeling of the left atrium: clinical and therapeutic implications for atrial fibrillation. J Am Coll Cardiol 2008;51:1-11. https://doi.org/10.1016/j.jacc.2007.09.026
  41. Pan NH; Tsao HM, Chang NC, Chen YJ, Chen SA. Aging dilates atrium and pulmonary veins: implications for the genesis of atrial fibrillation. Chest 2008;133:190-6. https://doi.org/10.1378/chest.07-1769