Surgical treatment of ventricular tachycardia after surgical repair of tetralogy of Fallot. Relation between intraoperative mapping and histological findings.

Misaki, Takuro; Tsubota, Makoto; Watanabe, Go; Watanabe, Yasuhiko; Matumoto, Y; Ishida, Kazuki; T, Iwa; Okada, R

doi:10.1161/01.cir.90.1.264

Cited by 52 publications

(21 citation statements)

References 26 publications

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“…10 In agreement with our findings, previous reports also have found VT to be due to macroreentry. 4,5,7 Misaki et al 6 described activation revolving around a myotomy scar with diastolic activity within the lateral RVOT wall consistent with the most common location of reentry circuit isthmuses in the present study.…”

Section: Previous Studiessupporting

confidence: 85%

“…RV incision and myectomy produce RVOT aneurysmal or akinetic regions in Ͼ50% of the patients. 27 Misaki et al 6 found surviving myocytes embedded in fibrous tissue in resected tissue from an RVOT region with delayed conduction, resembling the histological findings in the border zone of infarcted myocardium. 6 Of interest, the postmortem specimen of the patient who survived 5 years after repair showed extreme thinning only of the anterolateral RVOT, consistent with isthmus 1 (Figure 4e).…”

Section: Previous Studiesmentioning

confidence: 78%

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Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease

et al. 2007

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Background— Catheter ablation of ventricular tachycardia (VT) after repair of congenital heart disease can be difficult because of nonmappable VTs and complex anatomy. Insights into the relation between anatomic isthmuses identified by delineating unexcitable tissue using substrate mapping techniques and critical reentry circuit isthmuses might facilitate ablation. Methods and Results— Sinus rhythm voltage mapping of the right ventricle was performed in 11 patients with sustained VT after repair of congenital heart disease. Unexcitable tissue from patch material, valve annulus, or dense fibrosis, identified from bipolar voltage (<0.5 mV) and pacing threshold (>10 mA), was defined as an anatomic isthmus boundary bordering 4 isthmuses between (1) the tricuspid annulus and scar/patch in the anterior right ventricular outflow, (2) the pulmonary annulus and right ventricular free wall scar/patch, (3) the pulmonary annulus and septal scar/patch, and (4) the septal scar/patch and tricuspid annulus. The reentry circuit isthmuses of all induced 15 VTs (mean cycle length, 276±78 ms; 73% poorly tolerated), identified by activation, entrainment, and/or pace mapping, were located in an anatomic isthmus (11 of 15 VTs in anatomic isthmus 1). Transecting the anatomic isthmuses by ablation lesions abolished all VTs. During 30.4±29.3 months of follow-up, 91% of patients remained free of VT. Conclusions— Reentry circuit isthmuses in VT late after repair of congenital heart disease are located within anatomically defined isthmuses bordered by unexcitable tissue. The boundaries can be identified with 3-dimensional substrate mapping and connected by ablation lines during sinus rhythm. These findings should facilitate catheter and surgical ablation of stable and unstable VTs.

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Section: Previous Studiessupporting

confidence: 85%

Section: Previous Studiesmentioning

confidence: 78%

Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease

et al. 2007

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“…12 Postrepair VT in the setting of TOF was originally classified as arising from both the OT and from the septal-inflow area of the RV where fractionated electrograms were commonly observed with their induction. 21,26,27 Follow-up studies based on excision of ventricular tissue at the time of arrhythmia surgery also demonstrated prominent fibrosis with subendocardial islets of surviving myocytes in the region of the RVOT. 21 The inclusion of a group of cases surviving surgical repair in the present analysis afforded an opportunity to evaluate these findings and confirm their consistent presence in the ventricular conduction isthmuses that have been more recently described in TOF.…”

mentioning

confidence: 98%

“…Isthmus 2, between the ventriculotomy and pulmonary annulus, was frequently described in the literature as a target for catheter ablation. [21][22][23][24] However, this isthmus was often absent secondary to a transannular incision or avoidance of RVOT incision altogether, and it is likely that with changes in surgical technique this isthmus will be encountered even less frequently with time. 4,6 Likewise, isthmus 4 was seen only occasionally and was noticeably uncommon in the older surgical survivors in the present series.…”

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confidence: 99%

Characterization of Anatomic Ventricular Tachycardia Isthmus Pathology After Surgical Repair of Tetralogy of Fallot

Moore

Seki

Shannon

et al. 2013

Circ: Arrhythmia and Electrophysiology

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The autopsy and surgical pathology databases at UCLA were searched for cases of TOF and its major variants (including TOF with pulmonary atresia and TOF with absent pulmonary valve). Baseline demographic and clinical data were obtained from the medical records. All specimens were evaluated for the presence of naturally or surgically related anatomic isthmuses corresponding to those that have been previously described. In addition, isthmus 1 was redesignated as 1A, 12 and © 2013 American Heart Association, Inc. Original ArticleBackground-Although catheter ablation has been used to target the critical isthmuses for re-entrant monomorphic ventricular tachycardia in tetralogy of Fallot, the anatomy and histology of these regions have not been fully characterized. Autopsy hearts with tetralogy of Fallot were evaluated to clarify the pathological substrate. Methods and Results-Twenty-seven hearts with the diagnosis of tetralogy of Fallot were examined. Anatomically defined isthmuses included (1A) ventriculotomy-to-tricuspid annulus, (1B) ventriculotomy-to-ventricular septal defect patch, (2) ventriculotomy-to-pulmonary annulus, (3) pulmonary annulus-to-ventricular septal defect patch, and (4) ventricular septal defect patch-to-tricuspid annulus. Length and wall thickness were measured for all specimens, and light microscopy was performed for those surviving surgery. For subjects ≥5 years at death, isthmuses 1A and 1B were present in 88%, isthmus 2 in 25%, isthmus 3 in 94%, and isthmus 4 in 13%. Isthmus 1A had the greatest dimensions (mean length, 3.9±1.08; thickness, 1.5±0.3 cm), isthmus 1B intermediate dimensions (mean length, 2.4±0.8; thickness, 1.1±0.4 cm), and isthmuses 2, 3, and 4 the smallest dimensions (mean length, 1.5±0.5, 1.4±0.8, and 0.6±0.4 cm; thickness, 0.5±0.2, 0.6±0.2, and 0.3±0.04 cm, respectively). Histological examination (n=7) revealed increased fibrosis in anatomic isthmuses relative to nonisthmus controls. Conclusions-Consistencies in isthmus dimensions and histology are found among patients with repaired tetralogy of Fallot. Isthmus 1A is associated with the largest morphological dimensions, whereas the nearby newly described isthmus 1B is significantly smaller. Of isthmuses with the smallest dimensions, isthmus 3 is the most common. (Circ Arrhythm Electrophysiol. 2013;6:905-911.)

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“…It is believed that a fraction of late arrhythmias in rTOF patients are acquired due to the formation of myocardial substrate caused by fibrotic scars after the repairing surgery [12,13]. Other long-standing risk factors are chronic pulmonary regurgitation (PR) and right ventricular outflow tract (RVOT) aneurysm which commonly coexist and have a proarrhythmic role [11].…”

Section: Late Arrhythmia In Rtof Patientsmentioning

confidence: 99%

Late arrhythmia in patients with repaired tetralogy of Fallot: who is at risk?

Grigaliūnas

Gumbienė

Valevičienė

et al. 2015

Seminars in Cardiovascular Medicine

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SummaryTetralogy of Fallot (TOF) is the most common cause of cyanotic congenital heart defect. Over the last century, the life expectancy of TOF patients has significantly improved. This, however, has brought new challenges both to patients and their health-care providers, the main of them being late arrhythmia. Ironically, late arrhythmia is predominantly generated due to the fibrotic scars caused by the life-saving surgical repair. Once the first two mainly arrhythmia-free decades after the repair pass, the risk of developing late arrhythmia and, therefore, SCD becomes substantial. Consequently, young adults with repaired Tetralogy of Fallot (rTOF) require careful outpatient monitoring.There have been many attempts to predict the risk of life-threatening arrhythmia in rTOF patients. This has led to the defining of various risk factors, ranging from the widely used QRS prolongation to novel predictors, derived from cardiac magnetic resonance (CMR) based anatomical findings (left ventricular dyssynchrony indexes, right ventricular output tract akinetic length, right ventricular mass-to-volume ratio). The latter predictors have recently established CMR as a tool of high significance in evaluation of rTOF patients.Although the role of Holter monitoring findings in rTOF patient-assessment remains unclear, it may be useful in those who are 25 years and older. Implantable cardioverter-defibrillator (ICD) implantation is the first-line treatment for secondary prevention of sudden cardiac death (SCD). rTOF patients suffer from the highest rate of inappropriate and the lowest rate of appropriate ICD shocks, when compared to other congenital heart diseases. As a consequence, ICD implantation for primary SCD prevention should be carefully weighed. Catheter-based ablation therapy leads to high rate of initial success when abolishing monomorphic ventricular tachycardia and intra-atrial reentrant tachycardia, however recurrence rates remain high. Seminars in Cardiovascular Medicine

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Surgical treatment of ventricular tachycardia after surgical repair of tetralogy of Fallot. Relation between intraoperative mapping and histological findings.

Cited by 52 publications

References 26 publications

Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease

Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease

Characterization of Anatomic Ventricular Tachycardia Isthmus Pathology After Surgical Repair of Tetralogy of Fallot

Late arrhythmia in patients with repaired tetralogy of Fallot: who is at risk?

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