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(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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