Abstract
Peri-operative electrophysiology study (EPS) in patients with tetralogy of Fallot (TOF) undergoing surgical pulmonary valve replacement (PVR) can predict subsequent ventricular arrhythmias (VAs) and intraoperative cryoablation can reduce post-operative VAs. Percutaneous PVR (PPVR) may cover critical anatomic isthmuses that limit future catheter ablation. The clinical predictors of inducible VAs and effects of catheter ablation in patients undergoing PPVR are not known. Explore the clinical predictors and effect of ablation on inducible VAs in TOF patients undergoing PPVR. Patients >25 yrs with TOF who underwent peri-PPVR EPS were identified. Demographics, cardiac imaging, and procedural characteristics were reviewed. Clinical and procedural characteristics were compared between patients with and without inducible VAs. Catheter ablation was performed in patients with inducible VAs. Sixteen patients were identified of which 7 (44%) had inducible VAs. Implanted valves/stents included Sapien™ (11), Melody™ (3), Alterra™ (2) and Harmony™ (1). Arrhythmias included monomorphic VT (4; 57%) and VF (3; 43%). Predictors of inducibility were infundibular resection at initial repair (p=0.04), severe RV dysfunction (p=0.03), and the presence of slowly conducting anatomic isthmuses (SCAIs) (p=0.02). Having only moderate RV dysfunction was protective (p=0.04). All inducible patients underwent ablation with 4 (56%) remaining inducible and having an ICD placed. Having monomorphic VT was predictive of being non-inducible following ablation (p=0.02). No sustained VAs were detected in follow-up (median 9.4 (5-13 mo)). Predictors of inducible VAs in TOF patients undergoing PPVR include prior infundibular resection, severe RV dysfunction, and SCAIs. Targeting SCAIs with ablation may prevent inducible monomorphic VT though percutaneous valves may cover critical isthmuses.
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