(Circulation. 2001;103:2489.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Impact of Pulmonary Valve Replacement on Arrhythmia Propensity Late After Repair of Tetralogy of Fallot
From the University of Toronto Congenital Cardiac Center for Adults, Toronto, Ontario, Canada (J.T., S.C.S., L.H., W.G.W., G.W., M.A.G.); the Montreal Heart Institute, Montreal, Quebec, Canada (A.D.); the Chiba Cardiovascular Center, Chiba, Japan (K.N.); and the Kardiocentrum, University Hospital Motol, Prague, Czech Republic (J.J.). Dr Gatzoulis is currently affiliated with the Adult Congenital Heart Program, Royal Brompton Hospital, London, UK.
Correspondence to Judith Therrien, Sir MB Davis Jewish General Hospital, 3755 Cote Ste Catherine, Montreal, Quebec, H3T 1E2 Canada. E-mail judiththerrien{at}hotmail.com
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionConclusionsReferences |
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Background—Chronic pulmonary regurgitation after repair of tetralogy of Fallot (TOF) may lead to right ventricular dilatation, which may be accompanied by ventricular tachycardia and sudden death. We aimed to examine the effects of pulmonary valve replacement (PVR) on (1) certain electrocardiographic markers predictive of monomorphic ventricular arrhythmia and sudden death and (2) sustained atrial flutter/fibrillation and monomorphic ventricular tachycardia.
Methods and Results—We studied 70 patients who underwent PVR for pulmonary regurgitation and/or right ventricular outflow tract obstruction late after repair of TOF. Maximum QRS duration and QT dispersion were measured from standard ECGs before PVR and at the latest follow-up. Arrhythmia was defined as sustained atrial flutter/fibrillation or sustained monomorphic ventricular tachycardia. Concomitant intraoperative electrophysiological mapping and/or cryoablation were performed in 9 patients (60%) with preexisting ventricular tachycardia and 6 patients (50%) with preexisting atrial flutter. QRS duration remained unchanged in the study group (P=0.46), but it was significantly prolonged (P<0.001) in a comparable group of patients with repaired TOF who did not undergo PVR. At a mean follow-up of 4.7 years, the incidence of ventricular tachycardia diminished from 22% to 9% (P<0.001), and atrial flutter/fibrillation decreased from 17% to 12% (P=0.32). Intraoperative ablation prevented recurrence of preexisting tachyarrhythmia (0 of 15 patients).
Conclusions—PVR in patients with previous TOF repair and chronic pulmonary regurgitation leads to stabilization of QRS duration and, in conjunction with intraoperative cryoablation, to a decrease in the incidence of preexisting atrial and ventricular tachyarrhythmia. When applicable, this combined approach should be used in patients late after repair of TOF.
Key Words: pulmonary valve • ablation • tetralogy of Fallot • heart diseases
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Intracardiac repair of tetralogy of Fallot (TOF) has been accomplished with success since the mid-1950s, with a favorable long-term outcome for the majority of patients.1 2 3 Chronic pulmonary regurgitation (PR), however, may be problematic and lead to right ventricular dilatation and exercise intolerance, and it may be accompanied by ventricular tachycardia and sudden death.4 5 Certain electrocardiographic markers, namely QRS prolongation6 7 8 9 and marked QT dispersion,9 correlate with right ventricular dilatation and are predictive of sustained monomorphic ventricular tachycardia and sudden death. Pulmonary valve replacement (PVR) in patients with substantial PR and impaired right-sided hemodynamics after TOF repair can be performed safely10 and results in a reduction of right ventricular dilatation and improved right ventricular function and exercise tolerance.11 12 13 However, little is known about the possible effects of PVR on some electrocardiographic predictors of monomorphic ventricular tachycardia and sudden death and on the fate of atrial flutter/fibrillation and ventricular tachycardia after PVR. We hypothesized that restoration of pulmonary valve competence with pulmonary valve implantation and reduction of PR may lead to stabilization or reduction of QRS duration and QT dispersion with a corresponding decrease in arrhythmia (namely, monomorphic ventricular tachycardia and atrial flutter/fibrillation).
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Methods |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Patient Population
From the databases of 4 participating hospitals, we identified all consecutive patients older than 18 years of age who underwent PVR for PR and/or right ventricular outflow tract obstruction late after repair of TOF. Twenty-eight patients (40%) were reported in previous studies.14 15 16 We reviewed and recorded surgical data, including initial palliative procedures, details of repair, and PVR. The clinical status of patients before PVR was ascertained from hospital records. Current or latest status of patients was assessed from clinic visits and patient or physician contact. Death and late sustained atrial flutter/fibrillation or sustained monomorphic ventricular tachycardia after PVR were the clinical end points of the study.
Echocardiographic
Analysis
Preoperative and postoperative (most recent) 2D color
Doppler and M-mode echocardiograms, obtained using different
commercially available machines, were reviewed for each patient. The
severity of the PR was assessed by pulse-wave Doppler
characteristics and color flow mapping, as previously
described,17 and it was
graded as mild, moderate, or severe. Degree of right
ventricular outflow tract obstruction was derived from the
peak velocity of the right ventricular outflow tract
obtained by continuous Doppler (P=4V2
where P indicates pressure and V, velocity). Right
ventricular dilatation was estimated from right
ventricular inlet measurements made at
end-diastole from apical 4-chamber
views.18 Right
ventricular enlargement was considered mild when the right
ventricular inlet measured between 40 and 50 mm,
moderate when it was between 50 and 60 mm, and severe when it was
>60 mm.
Electrocardiographic Measurements
Preoperative (baseline) and late postoperative (most
recent) electrocardiographic parameters (RR interval, QRS
duration, and QT dispersion) were analyzed manually by a
cardiologist who was blinded to clinical data. Standard (speed, 25
mm/s and 1 mV/cm standardization) resting 12-lead ECGs were used. QRS
duration was defined as the maximal QRS length in any lead from the
first inflection to the final sharp vector crossing the isoelectric
line. QT dispersion was defined as the maximal QT interval minus the
minimal QT interval in any of the 12 leads. QT interval was measured
from the first inflection of the Q wave to the final sharp vector of
the T wave crossing the isoelectric line. U waves were not included in
the QT interval measurement when prominent (U wave >50% of T wave or
biphasic).6 7 8 9
Serial ECGs of 30 patients (control group) with repaired tetralogy and moderate to severe PR who had not undergone PVR by the study’s end (matched for age at repair and length of follow-up with the patients who had PVR) were analyzed in a similar manner.
Arrhythmia
Significant arrhythmia was defined as (1)
sustained atrial flutter/fibrillation or sustained monomorphic
ventricular tachycardia documented on a 12
lead-ECG, Holter recording, or electrocardiographic strips or
(2) palpitations associated with syncope or near syncope in patients
who were subsequently found to have inducible sustained atrial
flutter/fibrillation or sustained monomorphic ventricular
tachycardia at
electrophysiological testing. Sustained was
defined as arrhythmia lasting >30 seconds or of any length of
time if associated with hemodynamic
compromise.
Atrial flutter/fibrillation and monomorphic ventricular tachycardia were classified as preoperative (ie, occurring before PVR) and late postoperative (ie, occurring after the first 3 postoperative months from PVR). The need for antiarrhythmic medication preoperatively and at the latest follow-up was also recorded for each patient.
Surgical Technique
PVR was performed through a median sternotomy using
standard cardiopulmonary bypass and mild systemic hypothermia
(32°C and 35°C). Bioprosthetic pulmonary valves
were sewn into the pulmonary annulus and covered with a patch
of autologous pericardium. The pericardial patch extended from the
pulmonary artery bifurcation to the right
ventricular infundibulum.
Intraoperative Cryoablation
The objective of ventricular and atrial
cryoablation was to identify and eliminate an area of slowed conduction
responsible for a reentry circuit, which is thought to be a necessary
substrate for monomorphic ventricular
tachycardia and atrial flutter, respectively, in this
patient population.
Monomorphic Ventricular
Tachycardia
Intraoperative
electrophysiological mapping was performed
in one center as previously
described19 20
using a customized right ventricular balloon electrode
array for recording endocardial activation along with a sock
positioned over the surface of the heart for epicardial
recording. This enabled the simultaneous
recording of endocardial and epicardial activation from 224
sites using a multiplex recording
system.20 Induction of
ventricular tachycardia was performed using a
standard pacing protocol from the right ventricular apex.
After induction and mapping, ventricular cryoablation was
performed over the critical areas using a 1 cm tip cryoprobe applied
down to -60°C for 2 minutes at a time.
Atrial Flutter
At the same center, for those patients with
documented atrial flutter preoperatively, intraoperative atrial
cryoablation was performed using a similar technique. The cryoprobe was
applied in a serial manner between the inferior vena cava
orifice and the tricuspid annulus.
Statistical Analysis
We analyzed the data using SPSS for Windows
(version 7.0). Descriptive data for continuous variables are
presented as mean±SD or as medians with ranges, when
appropriate. Discrete variables were analyzed by
2 or Fisher’s exact tests. Comparisons
of continuous data between study and control groups were performed
using 2-sample t tests or the
Wilcoxon rank-sum test, wherever appropriate. Pair-wise
comparisons of continuous variables within each group were
performed using a paired t test
or Wilcoxon sign rank test. The probability of survival and
freedom from preexisting sustained atrial flutter/fibrillation or
monomorphic ventricular tachycardia over time
is displayed with Kaplan-Meier
plots.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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Patients
A total of 70 patients, 33 male (47%) and 37 female (53%), fulfilled entry criteria. Forty patients (60%) had
1
palliative procedure before intracardiac repair, most commonly a
Blalock-Taussig shunt (48%). Median age at TOF repair was 7.0 years
(range, 1 to 40 years). A transannular patch was used in 39% of the
patients
(Table 1
). Before PVR, 12 patients (18%) were in New
York Heart Association (NYHA) functional class III or IV. Twelve
patients (17%) had experienced atrial flutter/fibrillation, and 15
patients (22%) had monomorphic ventricular
tachycardia at a median time of 4 years (range, 6 weeks to
24 years) before PVR. Indications for PVR were (1) exercise
intolerance, (2) progressive right ventricular dilatation
(identified from serial transthoracic
echocardiographic studies), and (3) clinical
arrhythmia, with most patients (55%) fulfilling 2 or 3
criteria. Four patients had isolated moderate-to-severe right
ventricular outflow tract obstruction (peak
Doppler gradient >50 mm Hg) without substantial PR. The
control group was composed of 30 adult patients (18 men) with previous
tetralogy repair and moderate-to-severe PR. Their surgical data are
presented in
Table 1. The control group only differed from the study
group in that they had not undergone PVR by the study end. The mean
time from repair to the study baseline ECG was 18.1 years for the study
group versus 21.1 years in the control group.
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Pulmonary Valve Replacement
PVR was performed at a median age of 28.2 years (range,
9.6 to 53.9 years), with a median time from repair to PVR of 16.8 years
(range, 3 to 36 years). Most patients (86%) received a xenograft
pulmonary valve; the valve size ranged from 21 to 34 mm.
Additional procedures performed at the time of PVR are listed in
Table 1
.
Survival
There were 3 perioperative deaths for
an operative mortality of 4%. Two deaths were due to multiorgan
failure, and one was due to intractable right-sided congestive heart
failure. All 3 patients had severe PR and severe right
ventricular enlargement at the time of PVR. At 3 and 9
years after PVR, 2 more patients died. Death was due to right-sided
heart failure in one patient and sudden death, presumably arrhythmic,
in the other. The latter patient did not have ventricular
arrhythmia preoperatively but had undergone residual
ventricular septal defect closure through a left
ventriculotomy and, subsequently, had developed
biventricular failure with a
hemodynamically significant residual
ventricular septal defect and intermittent right-sided
monomorphic ventricular tachycardia.
Probability of survival after PVR was 92% at 5 years and 86% at 10
years
(Figure 1).
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Current Status
Functional and Hemodynamic
Data
Functional and hemodynamic data are
shown in
Table 2. At the latest follow up, only 6% of patients were
in NYHA functional class III to IV after PVR compared with 18% before
PVR (P=0.009).
Moderate-to-severe right ventricular dilatation, as
assessed by transthoracic
echocardiography, was also decreased by study end
to 37% of patients compared with 71% preoperatively
(P<0.001).
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Electrocardiographic Markers
ECG measurements are shown in
Table 2. At a mean of 4.7 years from PVR, mean QRS duration
remained unchanged (mean of 178 ms preoperatively to 176 ms at latest
follow-up; P=0.46;
Figure 2). QT dispersion likewise remained unchanged after
PVR. In contrast, mean QRS duration prolonged significantly (from 171
ms to181 ms; P<0.001;
Figure 2) over a similar length of follow up (4.9 years) in
the control group of repaired tetralogy patients who had not undergone
PVR by the study end. QT dispersion in the control group, like the
group with PVR, remained unchanged.
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Arrhythmias
The incidence of monomorphic ventricular
tachycardia decreased from 22% preoperatively to 9%
postoperatively (P<0.001).
Atrial flutter/fibrillation decreased from 17% preoperatively to 12%
postoperatively (P=0.32;
Figure 3).
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Role of Cryoablation
Of the 15 patients with monomorphic
ventricular tachycardia preoperatively, 9
patients underwent concomitant intraoperative mapping and
ventricular cryoablation at the time of pulmonary
valve implant. Postoperatively, none of them had recurrent
ventricular tachycardia, whereas 2 of 6
patients who had not undergone ventricular cryoablation at
the time of surgery had recurrent monomorphic ventricular
arrhythmia (P<0.001).
Of the 12 patients with atrial flutter/fibrillation before surgery, 6
underwent atrial cryoablation at the time of pulmonary valve
implant. All 6 patients remained free of atrial
tachyarrhythmia at follow-up, whereas 4 out of 6
patients who had not undergone atrial cryoablation had recurrent atrial
flutter at follow-up
(P<0.001).
Freedom from preexisting atrial flutter/fibrillation or
ventricular tachycardia was 100% at 5 years in
patients with concomitant intraoperative cryoablation compared with
68% at 5 years in patients receiving no concomitant cryoablation at
the time of PVR (P=0.055;
Figure 4). One patient who underwent cryoablation for
monomorphic ventricular tachycardia
subsequently developed supraventricular
tachycardia after
PVR.
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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This study provides, for the first time, evidence that PVR late after TOF repair has a stabilizing effect on QRS duration and, in conjunction with intraoperative cryoablation, leads to a decrease in the incidence of preexisting atrial and ventricular tachyarrhythmia.
Mortality
PVR has been performed with a low operative mortality
of 2% and a reported 10-year survival rate of 92% to
95%.10 11 12 13 14
Perioperative mortality in the present multicenter
study was 4%, with a 10-year survival of 86%. Patients from our
series were older at the time of PVR than in the previous series (mean
age, 27.8 years versus 17.4
years).10 11 12 13
All patients who suffered perioperative death in our
study had established advanced right ventricular
dysfunction, suggesting that delayed PVR may have contributed to poor
outcome.
Functional Status
Functional status improved after PVR, with a
concomitant decrease in right ventricular dilatation as
assessed by transthoracic
echocardiography. Our data are in accord with
previous published reports by Warner et
al11 and Bove et
al13 but in some
disagreement with recent data published by our group regarding the
effect of PVR on right ventricular
volume.21 Younger age at PVR
in this larger cohort of patients from the present study, as well
as the use of echocardiography, at best a
semiquantitative method of measuring right ventricular
size, may explain the differences observed.
ECG Markers
QRS duration after PVR remained stable at a mean
follow-up of 4.7 years. In contrast, there was a significant interval
increase in QRS duration in the control group. The data from the
present study are in accord with our recent longitudinal report of
793 adults with repaired TOF in whom QRS duration increased by an
average of 2 ms per year for the whole
group.16 QRS prolongation
after repair of TOF reflects abnormal and delayed
ventricular depolarization and correlates with the degree
of right ventricular
dilatation.6 7 8
Furthermore, a QRS duration >180 ms is a sensitive predictor of sudden
death.6 The QRS prolongation
observed in our control group suggests progressive right
ventricular dilatation in this group of patients with
repaired TOF and moderate to severe PR but no PVR. This is analogous to
the effect of chronic left-sided regurgitant lesions on their recipient
ventricular
chambers.22 23
Stabilization of the QRS complex in the study group would suggest
stabilization of right ventricular volume or alternatively,
according to our echocardiographic data, a reduction in
right ventricular volume counteracted by further
"damage" of the conduction tissue at the time of PVR
(aneurysm plication, infundibulectomy, closure of residual
ventricular septal defect), leading to an overall
stabilization of QRS complex to preoperative baseline
levels.
Reduction in Arrhythmias
A significant reduction in the incidence of preexisting
monomorphic ventricular tachycardia after PVR
was observed. Furthermore, patients undergoing concomitant cryotherapy
for ventricular or atrial arrhythmia had a greater
chance to remain arrhythmia-free over time
(P=0.055). Given the clearly
divergent curves on
Figure 4, we think that statistical significance
(P<0.05) was not reached in
this analysis because of the relatively small group size. A
similar trend was previously suggested by the work of Oechslin et
al14 and Harrison et
al.15
Right ventricular enlargement from chronic PR is a common hemodynamic substrate in patients with repaired TOF who develop sustained monomorphic ventricular tachycardia.4 5 It is thought that right ventricular myocardial stretch engenders areas of inhomogeneous electrical activity,24 25 predisposing to the development of ventricular arrhythmia.6 24 25 26 Right ventricular scar tissue from prior ventriculotomy, however, may provide areas of slowed ventricular activation,27 further facilitating the development of reentry.28 29 30 Similarly, right atrial dilatation from volume or pressure load prolongs atrial refractoriness in a heterogeneous manner. This dilatation, together with right atrial scarring from previous surgery,31 makes the atria susceptible to reentrant arrhythmia.32 Our data suggest that to abolish preexisting arrhythmias, ventricular or supraventricular, a combined approach is needed that addresses not only cavity dilatation but also focuses on the arrhythmia (the areas of slowed conduction) with concomitant cryotherapy.
Longevity of Pulmonary Valve
Prosthesis
The average life span of a bioprosthesis or
homograft pulmonary valve varies from 7 to 15
years.33 The need for repeat
pulmonary valve surgery in these patients is a cause of
concern. It may be that different valves, such as single-disk
mechanical prostheses, which were recently shown to be safe and less
thrombogenic than previously
thought,34
will eliminate the need for multiple operations in the right
ventricular outflow tract for these patients. This is
speculative, however. At present, preservation of right
ventricular function with PVR has to be weighed against
possible further cardiac surgery.
Limitations of the Study
Our study reports on an intention-to-treat cohort and
therefore cannot directly answer the question of whether PVR with or
without cryotherapy should be performed in all patients with previous
repair of TOF and similar hemodynamics. Selection
criteria for PVR in the study were clinically determined, and we think
they are representative of current practice for adults
with repaired
TOF.35 Previous
aortopulmonary shunts in patients with tetralogy repair and
long-standing left heart volume overload may also lead to
arrhythmia originating from the left side. The principal focus
of our study, however, was on the right ventricle and its
well-documented potential to develop sustained ventricular
tachycardia. Larger scale, prospective studies with
complete datasets may clarify the role of PVR in adult survivors of
tetralogy repair.
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Conclusions |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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We showed that in patients with repaired TOF and progressive right ventricular dilatation, exercise intolerance, symptomatic atrial flutter/fibrillation, or monomorphic ventricular tachycardia, PVR leads to a stabilization of QRS duration. Furthermore, PVR in these patients, when combined with intraoperative cryoablation, leads to a decrease in the incidence rate of preexisting atrial and ventricular tachyarrhythmias. When applicable, this combined approach should be used in patients late after TOF repair.
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Acknowledgments |
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Dr Janousek was sponsored by grant NA/4596-3 of the Internal Grant Agency of the Ministry of Health of the Czech Republic. We thank Nicole Whitely for helping with data acquisition.
Received December 4, 2000; revision received February 23, 2001; accepted March 1, 2001.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionsReferences |
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D. M. Harrild, C. I. Berul, F. Cecchin, T. Geva, K. Gauvreau, F. Pigula, and E. P. Walsh Pulmonary Valve Replacement in Tetralogy of Fallot: Impact on Survival and Ventricular Tachycardia Circulation, January 27, 2009; 119(3): 445 - 451. [Abstract] [Full Text] [PDF]
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C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease) Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., December 2, 2008; 52(23): e143 - e263. [Full Text] [PDF]
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C. A. Warnes, R. G. Williams, T. M. Bashore, J. S. Child, H. M. Connolly, J. A. Dearani, P. del Nido, J. W. Fasules, T. P. Graham Jr, Z. M. Hijazi, et al. ACC/AHA 2008 Guidelines for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease): Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, December 2, 2008; 118(23): e714 - e833. [Full Text] [PDF]
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2006 WRITING COMMITTEE MEMBERS, R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons Circulation, October 7, 2008; 118(15): e523 - e661. [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons J. Am. Coll. Cardiol., September 23, 2008; 52(13): e1 - e142. [Full Text] [PDF]
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K. Zeppenfeld, M. J. Schalij, M. M. Bartelings, U. B. Tedrow, B. A. Koplan, K. Soejima, and W. G. Stevenson Catheter Ablation of Ventricular Tachycardia After Repair of Congenital Heart Disease: Electroanatomic Identification of the Critical Right Ventricular Isthmus Circulation, November 13, 2007; 116(20): 2241 - 2252. [Abstract] [Full Text] [PDF]
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A. Uebing, D. G. Gibson, S. V. Babu-Narayan, G. P. Diller, K. Dimopoulos, O. Goktekin, M. S. Spence, K. Andersen, M. Y. Henein, M. A. Gatzoulis, et al. Right Ventricular Mechanics and QRS Duration in Patients With Repaired Tetralogy of Fallot: Implications of Infundibular Disease Circulation, October 2, 2007; 116(14): 1532 - 1539. [Abstract] [Full Text] [PDF]
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A. Gengsakul, L. Harris, T. J. Bradley, G. D. Webb, W. G. Williams, S. C. Siu, N. Merchant, and B. W. McCrindle The impact of pulmonary valve replacement after tetralogy of Fallot repair: a matched comparison Eur. J. Cardiothorac. Surg., September 1, 2007; 32(3): 462 - 468. [Abstract] [Full Text] [PDF]
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R. R Chaturvedi and A. N Redington Pulmonary regurgitation in congenital heart disease Heart, July 1, 2007; 93(7): 880 - 889. [Full Text] [PDF]
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T. Oosterhof, H. W Vliegen, F. J Meijboom, A. H Zwinderman, B. Bouma, and B. J M Mulder Long-term effect of pulmonary valve replacement on QRS duration in patients with corrected tetralogy of Fallot Heart, April 1, 2007; 93(4): 506 - 509. [Abstract] [Full Text] [PDF]
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I. R. Henkens, A. van Straten, M. J. Schalij, M. G. Hazekamp, A. de Roos, E. E. van der Wall, and H. W. Vliegen Predicting Outcome of Pulmonary Valve Replacement in Adult Tetralogy of Fallot Patients Ann. Thorac. Surg., March 1, 2007; 83(3): 907 - 911. [Abstract] [Full Text] [PDF]
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E. P. Walsh and F. Cecchin Arrhythmias in Adult Patients With Congenital Heart Disease Circulation, January 30, 2007; 115(4): 534 - 545. [Full Text] [PDF]
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R. O. Bonow, B. A. Carabello, K. Chatterjee, A. C. de Leon Jr, D. P. Faxon, M. D. Freed, W. H. Gaasch, B. W. Lytle, R. A. Nishimura, P. T. O'Gara, et al. ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Developed in Collaboration With the Society of Cardiovascular Anesthesiologists Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons J. Am. Coll. Cardiol., August 1, 2006; 48(3): e1 - e148. [Full Text] [PDF]
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H. Dave, A. Dodge-Khatami, A. Kadner, and R. Pretre Modified Technique for Heterotopic Implantation of a Right Ventricular Outflow Tract Conduit Ann. Thorac. Surg., June 1, 2006; 81(6): 2321 - 2323. [Abstract] [Full Text] [PDF]
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P A Davlouros, K Niwa, G Webb, and M A Gatzoulis The right ventricle in congenital heart disease Heart, April 1, 2006; 92(suppl_1): i27 - i38. [Abstract] [Full Text] [PDF]
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S. V. Babu-Narayan, P. J. Kilner, W. Li, J. C. Moon, O. Goktekin, P. A. Davlouros, M. Khan, S. Y. Ho, D. J. Pennell, and M. A. Gatzoulis Ventricular Fibrosis Suggested by Cardiovascular Magnetic Resonance in Adults With Repaired Tetralogy of Fallot and Its Relationship to Adverse Markers of Clinical Outcome Circulation, January 24, 2006; 113(3): 405 - 413. [Abstract] [Full Text] [PDF]
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R. D. Stewart, C. L. Backer, L. Young, and C. Mavroudis Tetralogy of Fallot: Results of a Pulmonary Valve-Sparing Strategy Ann. Thorac. Surg., October 1, 2005; 80(4): 1431 - 1439. [Abstract] [Full Text] [PDF]
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S. Khambadkone, L. Coats, A. Taylor, Y. Boudjemline, G. Derrick, V. Tsang, J. Cooper, V. Muthurangu, S. R. Hegde, R. S. Razavi, et al. Percutaneous Pulmonary Valve Implantation in Humans: Results in 59 Consecutive Patients Circulation, August 23, 2005; 112(8): 1189 - 1197. [Abstract] [Full Text] [PDF]
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C. A. Warnes The Adult With Congenital Heart Disease: Born To Be Bad? J. Am. Coll. Cardiol., July 5, 2005; 46(1): 1 - 8. [Abstract] [Full Text] [PDF]
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B. H. van Huysduynen, A. van Straten, C. A. Swenne, A. C. Maan, H. J. Ritsema van Eck, M. J. Schalij, E. E. van der Wall, A. de Roos, M. G. Hazekamp, and H. W. Vliegen Reduction of QRS duration after pulmonary valve replacement in adult Fallot patients is related to reduction of right ventricular volume Eur. Heart J., May 1, 2005; 26(9): 928 - 932. [Abstract] [Full Text] [PDF]
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E. A. Stephenson and A. N. Redington Reduction of QRS duration following pulmonary valve replacement in tetralogy of Fallot: implications for arrhythmia reduction? Eur. Heart J., May 1, 2005; 26(9): 863 - 864. [Full Text] [PDF]
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L. Coats, V. Tsang, S. Khambadkone, C. van Doorn, S. Cullen, J. Deanfield, M. R. de Leval, and P. Bonhoeffer The potential impact of percutaneous pulmonary valve stent implantation on right ventricular outflow tract re-intervention Eur. J. Cardiothorac. Surg., April 1, 2005; 27(4): 536 - 543. [Abstract] [Full Text] [PDF]
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J. A. Quintessenza, J. P. Jacobs, V. O. Morell, J. M. Giroud, and R. J. Boucek Initial Experience With a Bicuspid Polytetrafluoroethylene Pulmonary Valve in 41 Children and Adults: A New Option For Right Ventricular Outflow Tract Reconstruction Ann. Thorac. Surg., March 1, 2005; 79(3): 924 - 931. [Abstract] [Full Text] [PDF]
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B. Bouzas, P. J. Kilner, and M. A. Gatzoulis Pulmonary regurgitation: not a benign lesion Eur. Heart J., March 1, 2005; 26(5): 433 - 439. [Abstract] [Full Text] [PDF]
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S K Srinathan, R S Bonser, B Sethia, S A Thorne, W J Brawn, and D J Barron Changing practice of cardiac surgery in adult patients with congenital heart disease Heart, February 1, 2005; 91(2): 207 - 212. [Abstract] [Full Text] [PDF]
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A. Frigiola, A.N. Redington, S. Cullen, and M. Vogel Pulmonary Regurgitation Is an Important Determinant of Right Ventricular Contractile Dysfunction in Patients With Surgically Repaired Tetralogy of Fallot Circulation, September 14, 2004; 110(11_suppl_1): II-153 - II-157. [Abstract] [Full Text] [PDF]
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C. Lim, J. Y. Lee, W.-H. Kim, S.-C. Kim, J.-Y. Song, S.-J. Kim, J.-H. Choh, and C. Whan Kim Early replacement of pulmonary valve after repair of tetralogy: is it really beneficial? Eur. J. Cardiothorac. Surg., May 1, 2004; 25(5): 728 - 734. [Abstract] [Full Text] [PDF]
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Committee Members, C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, et al. ACC/AHA/ESC guidelines for the management of patients with supraventricular arrhythmias --executive summary: a report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines (writing committee to develop guidelines for the management of patients with supraventricular arrhythmias) Developed in Collaboration with NASPE-Heart Rhythm Society J. Am. Coll. Cardiol., October 15, 2003; 42(8): 1493 - 1531. [Full Text] [PDF]
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C. Blomstrom-Lundqvist, M. M. Scheinman, E. M. Aliot, J. S. Alpert, H. Calkins, A. J. Camm, W. B. Campbell, D. E. Haines, K. H. Kuck, B. B. Lerman, et al. ACC/AHA/ESC Guidelines for the Management of Patients With Supraventricular Arrhythmias*--Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Supraventricular Arrhythmias) Circulation, October 14, 2003; 108(15): 1871 - 1909. [Full Text] [PDF]
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K. G. Warner, P. K. H. O'Brien, J. Rhodes, A. Kaur, D. A. Robinson, and D. D. Payne Expanding the indications for pulmonary valve replacement after repair of tetralogy of fallot Ann. Thorac. Surg., October 1, 2003; 76(4): 1066 - 1071. [Abstract] [Full Text] [PDF]
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P. A. Davlouros, P. J. Kilner, T. S. Hornung, W. Li, J. M. Francis, J. C. C. Moon, G. C. Smith, T. Tat, D. J. Pennell, and M. A. Gatzoulis Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction J. Am. Coll. Cardiol., December 4, 2002; 40(11): 2044 - 2052. [Abstract] [Full Text] [PDF]
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A. Ghai, C. Silversides, L. Harris, G. D. Webb, S. C. Siu, and J. Therrien Left ventricular dysfunction is a risk factor for sudden cardiac death in adults late after repair of tetralogy of fallot J. Am. Coll. Cardiol., November 6, 2002; 40(9): 1675 - 1680. [Abstract] [Full Text] [PDF]
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H. W. Vliegen, A. van Straten, A. de Roos, A. A.W. Roest, P. H. Schoof, A. H. Zwinderman, J. Ottenkamp, E. E. van der Wall, and M. G. Hazekamp Magnetic Resonance Imaging to Assess the Hemodynamic Effects of Pulmonary Valve Replacement in Adults Late After Repair of Tetralogy of Fallot Circulation, September 24, 2002; 106(13): 1703 - 1707. [Abstract] [Full Text] [PDF]
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B. S. Allen, C. El-Zein, B. Cuneo, J. P. Cava, M. J. Barth, and M. N. Ilbawi Pericardial tissue valves and gore-tex conduits as an alternative for right ventricular outflow tract replacement in children Ann. Thorac. Surg., September 1, 2002; 74(3): 771 - 777. [Abstract] [Full Text] [PDF]
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J G J Neffke, I I Tulevski, E E van der Wall, A A M Wilde, D J van Veldhuisen, A Dodge-Khatami, and B J M Mulder ECG determinants in adult patients with chronic right ventricular pressure overload caused by congenital heart disease: relation with plasma neurohormones and MRI parameters Heart, September 1, 2002; 88(3): 266 - 270. [Abstract] [Full Text] [PDF]
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K. R. Kanter, J. M. Budde, W. J. Parks, V. K.H. Tam, S. Sharma, W. H. Williams, and D. A. Fyfe One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction Ann. Thorac. Surg., June 1, 2002; 73(6): 1801 - 1807. [Abstract] [Full Text] [PDF]
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