Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California.
Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California.
Heart Rhythm. 2023 Dec;20(12):1689-1696. doi: 10.1016/j.hrthm.2023.08.020. Epub 2023 Aug 19.
Patients with repaired tetralogy of Fallot (TOF) are at risk for ventricular tachycardia (VT) related to well-described anatomical isthmuses.
The purpose of this study was to explore QRS morphology as an indicator of anatomical isthmus conduction.
Patients with repaired TOF and complete right bundle branch block referred for transcatheter pulmonary valve replacement (PVR) or presenting with sustained VT underwent comprehensive 3-dimensional mapping in sinus rhythm. Electrocardiographic characteristics were compared to right ventricular (RV) activation and anatomical isthmus conduction properties.
Twenty-two patients (19 pre-pulmonary valve replacement and 3 clinical VT) underwent comprehensive 3-dimensional mapping (median 39 years; interquartile range [IQR] 27-48 years; 12 [55%] male). Septal RV activation (median 40 ms; IQR 34-46 ms) corresponded to the nadir in lead V and free wall activation (median 71 ms; IQR 64-81 ms) to the transition point in the upstroke of the R' wave. Patients with isthmus block between the pulmonary annulus and the ventricular septal defect patch and between the ventricular septal defect patch and the tricuspid annulus (when present), were more likely to demonstrate lower amplitude R' waves in lead V (5.8 mV vs 9.4 mV; P = .005), QRS fragmentation in lead V (15 [94%] vs 2 [13%]; P < .001), and terminal S waves in lead aVF (15 [94%] vs 6 [40%]; P < .001) than those with intact conduction. During catheter ablation, these QRS changes developed during isthmus block.
For patients with repaired TOF, the status of septal isthmus conduction was evident from sinus rhythm QRS morphology. Low-amplitude, fragmented R' waves in lead V and terminal S waves in the inferior leads were related to septal isthmus conduction abnormalities, providing a mechanistic link between RV activation and common electrocardiographic findings.
修复后的法洛四联症（TOF）患者存在与描述明确的解剖峡部相关的室性心动过速（VT）风险。
本研究旨在探讨 QRS 形态作为解剖峡部传导的指标。
接受经导管肺动脉瓣置换术（PVR）或持续性 VT 的修复性 TOF 患者在窦性心律下接受全面的 3 维映射。比较心电图特征与右心室（RV）激活和解剖峡部传导特性。
22 例患者（19 例在肺动脉瓣置换前，3 例为临床 VT）接受全面的 3 维映射（中位数 39 岁；四分位距[IQR] 27-48 岁；12[55%]男性）。间隔 RV 激活（中位数 40 ms；IQR 34-46 ms）对应 V 导联的最低点，游离壁激活（中位数 71 ms；IQR 64-81 ms）对应 R'波上升的转折点。在肺动脉瓣环与室间隔缺损补片之间以及室间隔缺损补片与三尖瓣环之间（如有）存在峡部阻滞的患者，V 导联 R'波振幅更低（5.8 mV 比 9.4 mV；P =.005），V 导联 QRS 碎裂更明显（15[94%]比 2[13%]；P <.001），aVF 导联终末 S 波更明显（15[94%]比 6[40%]；P <.001），而非完整传导患者。在导管消融期间，峡部阻滞时出现这些 QRS 改变。
对于修复后的 TOF 患者，窦性心律 QRS 形态可明显显示间隔峡部传导状态。V 导联低振幅、碎裂的 R'波和下导联终末 S 波与间隔峡部传导异常有关，为 RV 激活与常见心电图表现之间提供了一种机制联系。
