Department of Congenital Cardiac Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
Department of Pediatric Congenital Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
Eur J Cardiothorac Surg. 2019 May 1;55(5):845-850. doi: 10.1093/ejcts/ezy407.
Life expectancy of patients with repaired tetralogy of Fallot is normal until adulthood, when it becomes burdened by major complications such as cardiac arrhythmias and heart failure. Ventricular tachycardia (VT), associated with electrical conduction abnormalities in anatomical isthmuses, is the most common complication and is refractory to medical therapy. The arrhythmogenic sources can be surgically ablated during reoperations for pulmonary valve incompetence. The purpose of our study is to evaluate the safety and effectiveness of surgical radiofrequency ablation during PVR and its long-term impact on the occurrence of cardiac events.
A total of 118 patients with repaired tetralogy of Fallot underwent reoperation for pulmonary valve regurgitation in IRCCS-Policlinico San Donato between January 2002 and February 2016. Twenty patients with risk factors for ventricular arrhythmia underwent EP testing and were found positive. The mean QRS duration was 178 ms. Right ventricular dysfunction was present in all the patients, and 20% had associated tricuspid regurgitation. The cohort (N = 20), with positive EP study, underwent pulmonary valve replacement and concomitant intraoperative ventricular surgical radiofrequency ablation, targeting the slow conducting isthmuses identified during preoperative electroanatomical mapping. All patients were reviewed at 1 month, 3 months and 6 months with clinical evaluation, echocardiography, ECG and implantable cardioverter-defibrillator interrogation. At 6 months, a postoperative electrophysiological study was performed in all patients, and a cardioverter defibrillator was implanted as primary preventive measure in patients with residual inducible VT.
Pulmonary valve replacement and surgical ventricular radiofrequency ablation were performed in all cases. One patient died while on V-V extracorporeal membrane oxygenation (ECMO) due to respiratory failure. There was no late mortality. Follow-up was complete with a median of 6.5 years. During the postoperative EPS study, inducible VT was found in 15.7% of patients who received an implantable cardioverter-defibrillator, whereas VT could no longer be induced in the remaining patients. No procedure-related complication was observed, and freedom from ventricular arrhythmia was 94% and 89.5% at 1 year and 5 years, respectively.
Pulmonary regurgitation and right ventricular dysfunction correlate with VT and SCD, but valve replacement alone does not reduce the risk of ventricular tachyarrhythmias. Intraoperative ventricular ablation during reoperation for pulmonary regurgitation prevents the occurrence of ventricular arrhythmias in the early and medium term. Accordingly, this technique may be proposed as a safe associated procedure in selected patients.
法洛四联症患者的预期寿命在成年前是正常的，但成年后会受到心律失常和心力衰竭等主要并发症的影响。室性心动过速（VT）与解剖峡部的电传导异常有关，是最常见的并发症，且对药物治疗有抗性。在因肺动脉瓣反流而进行的再次手术中，可以对致心律失常源进行手术消融。我们的研究目的是评估再次手术中经皮射频消融治疗肺动脉瓣反流的安全性和有效性，以及其对心脏事件发生的长期影响。
2002 年 1 月至 2016 年 2 月，共有 118 例法洛四联症患者在 IRCCS-Policlinico San Donato 接受了因肺动脉瓣反流而进行的再次手术。20 例有室性心律失常风险的患者进行了电生理检查，结果呈阳性。平均 QRS 持续时间为 178ms。所有患者均存在右心室功能障碍，20%的患者存在三尖瓣反流。该队列（N=20）在电生理检查阳性后，接受了肺动脉瓣置换术和术中右心室外科射频消融术，以针对术前电生理标测中识别的缓慢传导峡部。所有患者均在 1 个月、3 个月和 6 个月时进行临床评估、超声心动图、心电图和植入式心脏复律除颤器检查。在 6 个月时，对所有患者进行了术后电生理研究，并对残留可诱导 VT 的患者植入了心脏复律除颤器作为初级预防措施。
所有患者均进行了肺动脉瓣置换术和外科射频消融术。1 例患者因呼吸衰竭在体外膜肺氧合（ECMO）期间死亡。无晚期死亡。中位随访时间为 6.5 年，随访完整。在术后电生理刺激研究中，15.7%接受植入式心脏复律除颤器的患者可诱发出 VT，而其余患者的 VT 无法再被诱发出。未观察到与手术相关的并发症，1 年和 5 年时的无室性心律失常率分别为 94%和 89.5%。
肺动脉瓣反流和右心室功能障碍与 VT 和 SCD 相关，但单独瓣膜置换并不能降低室性心动过速的风险。在因肺动脉瓣反流而进行的再次手术中进行术中右心室消融术，可以在早期和中期预防室性心律失常的发生。因此，该技术可作为一种安全的选择，在选定的患者中作为相关手术。
