(Circulation. 1995;92:231-237.)
© 1995 American Heart Association, Inc.
Articles |
Mechanoelectrical Interaction in Tetralogy of Fallot
QRS Prolongation Relates to Right Ventricular Size and Predicts Malignant Ventricular Arrhythmias and Sudden Death
From the Department of Paediatric Cardiology (M.A.G., J.A.T., A.N.R.), Grown-up Congenital Heart Unit (J.S.), Royal Brompton Hospital and National Heart and Lung Institute, London, England.
Correspondence to Dr Andrew N. Redington, Department of Paediatric Cardiology, Royal Brompton Hospital/National Heart and Lung Institute, Sydney St, London, UK, SW3 6NP.
Background Life-threatening ventricular arrhythmia and sudden death remain serious late complications after tetralogy of Fallot repair. Nevertheless, there remains no clear way of predicting which patients are at risk.
Methods and Results The study population included a total
of 178 adult survivors (mean follow-up, 21.4 years) of tetralogy of
Fallot repair who were currently attending our clinic.
Mechanoelectrical relations were sought in 41 of the patients (mean
follow-up, 23.6 years) who were operated on by one surgeon and who were
prospectively studied with a 12-lead ECG, chest radiography, and
two-dimensional and Doppler echocardiography. Nine patients (mean
follow-up, 17 years) from the total group of 178 were identified as
having had sustained ventricular tachycardia (8 with near-miss sudden
death), and their ECGs, Holter monitor readings, electrophysiological
studies, and chest radiographs were reviewed. The case notes of an
additional 4 patients with postoperative sudden cardiac death also were
available for review. QRS duration in the 41 patients in whom
mechanoelectrical interaction was sought ranged between 90 and 200
milliseconds and correlated with cardiothoracic ratio (CTR) on chest
radiography (r=.64, P<.001) and with right
ventricular size on echocardiography (r=.43,
P<.02). Twenty of the 41 patients had restrictive right
ventricular Doppler physiology (reduced ventricular compliance) with
mean QRS duration of 129.3±20 milliseconds and mean CTR of
0.51±0.03.
The remaining 21 patients with no evidence of right ventricular
restriction had prolonged QRS duration of 157.5±13.2 milliseconds
(P<.001) and CTR of 0.55±0.04 (P<.04) compared
with the restrictive. In the 9 patients with ventricular tachycardia,
the QRS duration ranged from 180 to 230 milliseconds (mean, 198.9±17.6
milliseconds), and the CTR ranged from 0.54 to 0.9 (mean, 0.67±0.12)
(P<.0001 and P<.01, respectively, compared with
patients without life-threatening arrhythmias). All patients with
documented sustained ventricular tachycardia and the 4 patients with
sudden death had a QRS duration of 
180 milliseconds (100%
sensitivity).
Conclusions Chronic right ventricular volume overload after
tetralogy of Fallot repair is related to diastolic function and
correlates with QRS prolongation. The risk of symptomatic arrhythmia is
high when marked right ventricular enlargement and QRS prolongation
develop. A QRS duration on the resting ECG of 180 milliseconds is the
most sensitive predictor of life-threatening ventricular arrhythmias
yet described.
Key Words: tetralogy of Fallot • arrhythmia • death • sudden • ventricles
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C. Alexiou, Q. Chen, M. Galogavrou, J. Gnanapragasam, A. P. Salmon, B. R. Keeton, M. P. Haw, and J. L. Monro Repair of tetralogy of Fallot in infancy with a transventricular or a transatrial approach Eur. J. Cardiothorac. Surg., August 1, 2002; 22(2): 174 - 183. [Abstract] [Full Text] [PDF]
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F. T.H. de Ruijter, I. Weenink, F. J. Hitchcock, E. J. Meijboom, and G. B.W.E. Bennink Right ventricular dysfunction and pulmonary valve replacement after correction of tetralogy of fallot Ann. Thorac. Surg., June 1, 2002; 73(6): 1794 - 1800. [Abstract] [Full Text] [PDF]
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A. Dodge-Khatami, O. I. Miller, R. H. Anderson, A. P. Goldman, J. M. Gil-Jaurena, M. J. Elliott, V. T. Tsang, and M. R. de Leval Surgical substrates of postoperative junctional ectopic tachycardia in congenital heart defects J. Thorac. Cardiovasc. Surg., April 1, 2002; 123(4): 624 - 630. [Abstract] [Full Text] [PDF]
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P. Turrini, D. Corrado, C. Basso, A. Nava, B. Bauce, and G. Thiene Dispersion of Ventricular Depolarization-Repolarization : A Noninvasive Marker for Risk Stratification in Arrhythmogenic Right Ventricular Cardiomyopathy Circulation, June 26, 2001; 103(25): 3075 - 3080. [Abstract] [Full Text] [PDF]
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A. R. Hosseinpour, R. H. Anderson, and S. Y. Ho The anatomy of the septal perforating arteries in normal and congenitally malformed hearts J. Thorac. Cardiovasc. Surg., June 1, 2001; 121(6): 1046 - 1052. [Abstract] [Full Text] [PDF]
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J. Therrien, S. C. Siu, L. Harris, A. Dore, K. Niwa, J. Janousek, W. G. Williams, G. Webb, and M. A. Gatzoulis Impact of Pulmonary Valve Replacement on Arrhythmia Propensity Late After Repair of Tetralogy of Fallot Circulation, May 22, 2001; 103(20): 2489 - 2494. [Abstract] [Full Text] [PDF]
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M.G. Hazekamp, M.M.J. Kurvers, P.H. Schoof, H.W. Vliegen, B.M. Mulder, A.A.W. Roest, J. Ottenkamp, and R.A.E. Dion Pulmonary valve insertion late after repair of Fallot's tetralogy Eur. J. Cardiothorac. Surg., May 1, 2001; 19(5): 667 - 670. [Abstract] [Full Text] [PDF]
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M. Vogel, J. Sponring, S. Cullen, J. E. Deanfield, and A. N. Redington Regional Wall Motion and Abnormalities of Electrical Depolarization and Repolarization in Patients After Surgical Repair of Tetralogy of Fallot Circulation, March 27, 2001; 103(12): 1669 - 1673. [Abstract] [Full Text] [PDF]
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C. Alexiou, H. Mahmoud, A. Al-Khaddour, J. Gnanapragasam, A. P. Salmon, B. R. Keeton, and J. L. Monro Outcome after repair of tetralogy of Fallot in the first year of life Ann. Thorac. Surg., February 1, 2001; 71(2): 494 - 500. [Abstract] [Full Text] [PDF]
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B. Discigil, J. A. Dearani, F. J. Puga, H. V. Schaff, D. J. Hagler, C. A. Warnes, and G. K. Danielson Late pulmonary valve replacement after repair of tetralogy of Fallot J. Thorac. Cardiovasc. Surg., February 1, 2001; 121(2): 0344 - 351. [Abstract] [Full Text] [PDF]
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S Brili, C Aggeli, K Gatzoulis, A Tzonou, C Hatzos, C Pitsavos, C Stefanadis, and P Toutouzas Echocardiographic and signal averaged ECG indices associated with non-sustained ventricular tachycardia after repair of tetralogy of Fallot Heart, January 1, 2001; 85(1): 57 - 60. [Abstract] [Full Text]
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J. Therrien, S. C. Siu, P. R. McLaughlin, P. P. Liu, W. G. Williams, and G. D. Webb Pulmonary valve replacement in adults late after repair of tetralogy of Fallot: are we operating too late? J. Am. Coll. Cardiol., November 1, 2000; 36(5): 1670 - 1675. [Abstract] [Full Text] [PDF]
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M A Gatzoulis, J Walters, P R McLaughlin, N Merchant, G D Webb, and P Liu Late arrhythmia in adults with the Mustard procedure for transposition of great arteries: a surrogate marker for right ventricular dysfunction? Heart, October 1, 2000; 84(4): 409 - 415. [Abstract] [Full Text]
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M Y A. El Rahman, H Abdul-Khaliq, M Vogel, V Alexi-Meskishvili, M Gutberlet, and P E Lange Relation between right ventricular enlargement, QRS duration, and right ventricular function in patients with tetralogy of Fallot and pulmonary regurgitation after surgical repair Heart, October 1, 2000; 84(4): 416 - 420. [Abstract] [Full Text]
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 M. E. Brickner, L. D. Hillis, and R. A. Lange Congenital Heart Disease in Adults- Second of Two Parts N. Engl. J. Med., February 3, 2000; 342(5): 334 - 342. [Full Text] [PDF]
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V. Rao, M. Kadletz, L. K. Hornberger, R. M. Freedom, and M. D. Black Preservation of the pulmonary valve complex in tetralogy of Fallot: how small is too small? Ann. Thorac. Surg., January 1, 2000; 69(1): 176 - 179. [Abstract] [Full Text] [PDF]
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R. R. Chaturvedi, D. F. Shore, C. Lincoln, S. Mumby, M. Kemp, J. Brierly, A. Petros, J. M.G. Gutteridge, J. Hooper, and A. N. Redington Acute Right Ventricular Restrictive Physiology After Repair of Tetralogy of Fallot : Association With Myocardial Injury and Oxidative Stress Circulation, October 5, 1999; 100(14): 1540 - 1547. [Abstract] [Full Text] [PDF]
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M. A. Norgaard, P. Lauridsen, M. Helvind, and G. Pettersson Twenty-to-thirty-seven-year follow-up after repair for Tetralogy of Fallot Eur. J. Cardiothorac. Surg., August 1, 1999; 16(2): 125 - 130. [Abstract] [Full Text] [PDF]
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E. N. Oechslin, D. A. Harrison, L. Harris, E. Downar, G. D. Webb, S. S. Siu, and W. G. Williams REOPERATION IN ADULTS WITH REPAIR OF TETRALOGY OF FALLOT: INDICATIONS AND OUTCOMES J. Thorac. Cardiovasc. Surg., August 1, 1999; 118(2): 245 - 251. [Abstract] [Full Text] [PDF]
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P. Schaffer, B. Pelzmann, E. Bernhart, P. Lang, H. Machler, B. Rigler, and B. Koidl Repolarizing currents in ventricular myocytes from young patients with tetralogy of Fallot Cardiovasc Res, August 1, 1999; 43(2): 332 - 343. [Abstract] [Full Text] [PDF]
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L Daliento, G Rizzoli, L Menti, M C Baratella, P Turrini, A Nava, and S Dalla Volta Accuracy of electrocardiographic and echocardiographic indices in predicting life threatening ventricular arrhythmias in patients operated for tetralogy of Fallot Heart, June 1, 1999; 81(6): 650 - 655. [Abstract] [Full Text]
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K A McLeod, W S Hillis, A B Houston, N Wilson, A Trainer, J Neilson, and W B Doig Reduced heart rate variability following repair of tetralogy of Fallot Heart, June 1, 1999; 81(6): 656 - 660. [Abstract] [Full Text]
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S. Conte, R. Jashari, B. Eyskens, M. Gewillig, M. Dumoulin, and W. Daenen Homograft valve insertion for pulmonary regurgitation late after valveless repair of right ventricular outflow tract obstruction Eur. J. Cardiothorac. Surg., February 1, 1999; 15(2): 143 - 149. [Abstract] [Full Text] [PDF]
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S. B. O'Blenes, D. B. Ross, M. A. Nanton, and D. A. Murphy Atrioventricular septal defect with tetralogy of fallot: results of surgical correction Ann. Thorac. Surg., December 1, 1998; 66(6): 2078 - 2082. [Abstract] [Full Text] [PDF]
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D. P. Zipes and H. J. J. Wellens Sudden Cardiac Death Circulation, November 24, 1998; 98(21): 2334 - 2351. [Full Text] [PDF]
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P. Munkhammar, S. Cullen, P. Jogi, M. de Leval, M. Elliott, and G. Norgard Early age at repair prevents restrictive right ventricular (RV) physiology after surgery for tetralogy of Fallot (TOF): Diastolic RV function after TOF repair in infancy J. Am. Coll. Cardiol., October 1, 1998; 32(4): 1083 - 1087. [Abstract] [Full Text] [PDF]
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G Norgård, M A Gatzoulis, M Josen, S Cullen, and A N Redington Does restrictive right ventricular physiology in the early postoperative period predict subsequent right ventricular restriction after repair of tetralogy of Fallot? Heart, May 1, 1998; 79(5): 481 - 484. [Abstract] [Full Text]
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I. M. Yemets, W. G. Williams, G. D. Webb, D. A. Harrison, P. R. McLaughlin, G. A. Trusler, J. G. Coles, I. M. Rebeyka, and R. M. Freedom Pulmonary Valve Replacement Late After Repair of Tetralogy of Fallot Ann. Thorac. Surg., August 1, 1997; 64(2): 526 - 530. [Abstract] [Full Text]
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R. R. Chaturvedi, P. J. Kilner, P. A. White, A. Bishop, R. Szwarc, and A. N. Redington Increased Airway Pressure and Simulated Branch Pulmonary Artery Stenosis Increase Pulmonary Regurgitation After Repair of Tetralogy of Fallot: Real-Time Analysis With a Conductance Catheter Technique Circulation, February 4, 1997; 95(3): 643 - 649. [Abstract] [Full Text]
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M. A. Gatzoulis, J. A. Till, and A. N. Redington Depolarization-Repolarization Inhomogeneity After Repair of Tetralogy of Fallot: The Substrate for Malignant Ventricular Tachycardia? Circulation, January 21, 1997; 95(2): 401 - 404. [Abstract] [Full Text]
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