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. 2016 Sep 30;5(10):e004325.
doi: 10.1161/JAHA.116.004325.

Percutaneous Pulmonary Valve Implantation Alters Electrophysiologic Substrate

Hoang H Nguyen  1 , Shabana Shahanavaz  1 , George F Van Hare  1 , David T Balzer  1 , Ramzi Nicolas  2 , Jennifer N Avari Silva  3
Affiliations

Percutaneous Pulmonary Valve Implantation Alters Electrophysiologic Substrate

Hoang H Nguyen et al. J Am Heart Assoc. .

Abstract

Background: Percutaneous pulmonary valve implantation (PPVI) is first-line therapy for some congenital heart disease patients with right ventricular outflow tract dysfunction. The hemodynamics improvements after PPVI are well documented, but little is known about its effects on the electrophysiologic substrate. The objective of this study is to assess the short- and medium-term electrophysiologic substrate changes and elucidate postprocedure arrhythmias.

Methods and results: A retrospective chart review of patients undergoing PPVI from May 2010 to April 2015 was performed. A total of 106 patients underwent PPVI; most commonly these patients had tetralogy of Fallot (n=59, 55%) and pulmonary insufficiency (n=60, 57%). The median follow-up time was 28 months (7-63 months). Pre-PPVI, 25 patients (24%) had documented arrhythmias: nonsustained ventricular tachycardia (NSVT) (n=9, 8%), frequent premature ventricular contractions (PVCs) (n=6, 6%), and atrial fibrillation/flutter (AF/AFL) (n=10, 9%). Post-PPVI, arrhythmias resolved in 4 patients who had NSVT (44%) and 5 patients who had PVCs (83%). New arrhythmias were seen in 16 patients (15%): 7 NSVT, 8 PVCs, and 1 AF/AFL. There was resolution at medium-term follow-up in 6 (86%) patients with new-onset NSVT and 7 (88%) patients with new-onset PVCs. There was no difference in QRS duration pre-PPVI, post-PPVI, and at medium-term follow-up (P=0.6). The median corrected QT lengthened immediately post-PPVI but shortened significantly at midterm follow-up (P<0.01).

Conclusions: PPVI reduced the prevalence of NSVT. The majority of postimplant arrhythmias resolve by 6 months of follow-up.

Keywords: arrhythmia (heart rhythm disorders); arrhythmia burden; electrocardiography; electrophysiology; percutaneous pulmonary valve placement; pulmonary valve.

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Figures

Figure 1
Figure 1
Comparison of RVOT pressure gradients of predominantly PS patients. There was a significant reduction in RVOT pressure gradients immediately post‐PPVI. These pressure gradients remained stable at follow‐up. RVOT indicates right ventricular outflow tract.
Figure 2
Figure 2
Comparison of ECG parameters. A, QRS duration (QRSd) is compared pre‐PPVI, post‐PPVI, and at follow‐up. There was no significant difference in QRSd among time points (P=0.6). B, Corrected QT interval (QTc, calculated using the Bazett formula) compared pre‐PPVI, post‐PPVI, and at follow‐up. The QTc was prolonged immediately post‐PPVI, but it significantly shortened at follow‐up (P<0.01). PPVI indicates percutaneous pulmonary valve implantation; QRSd, QRS duration; QTc, corrected QT interval.
Figure 3
Figure 3
ST depression on ECG. Five patients had ST depression pre‐PPVI. Immediately postprocedure, there was resolution of ST depression in 2 (40%) patients, while 3 (60%) patients continued to have unchanged ST depression. Patients who had resolved ST depression post‐PPVI did not have further ECGs at follow‐up. Additionally, 1 patient had a new‐onset ST depression on ECG. Both the new‐onset and persistent ST depression postprocedure resolved at follow‐up. PPVI indicates percutaneous pulmonary valve implantation.
Figure 4
Figure 4
T‐wave pattern on ECG. Seven patients had T‐wave inversion pre‐PPVI. Immediately postprocedure, there was resolution of T‐wave inversion in 4 (57%) patients, while 3 (43%) patients continued to have unchanged T‐wave inversion. Patients who had resolved T‐wave inversion post‐PPVI did not have further ECGs at follow‐up. Additionally, 5 patients had a new finding of T‐wave inversion on ECG. All new‐onset T‐wave inversions and 2 of 3 persistent T‐wave inversions postprocedure resolved at follow‐up. One patient with persistent postprocedure T‐wave inversion continued to have T‐wave inversion at follow‐up. Finally, 4 patients had new T‐wave inversions at follow‐up. PPVI indicates percutaneous pulmonary valve implantation.
Figure 5
Figure 5
Nonspecific ST/T changes on ECG. Eleven patients had ST/T changes pre‐PPVI. Immediately postprocedure, there was resolution of ST/T changes in 3 (27%) patients, while 8 (73%) patients continued to have unchanged ST/T changes. Patients who had resolved ST/T changes post‐PPVI did not have further ECGs at follow‐up. Additionally, 5 patients had a new finding of ST/T changes on ECG. All new‐onset ST/T changes and 3 of 8 (38%) persistent ST/T changes postprocedure resolved at follow‐up. Two patients with persistent postprocedure ST/T changes continued to have ST/T changes at follow‐up. Finally, 1 patient had new ST/T changes at follow‐up. Of note, 3 patients were lost to follow‐up. PPVI indicates percutaneous pulmonary valve implantation.
Figure 6
Figure 6
Documented nonsustained ventricular tachycardia (NSVT). Prior to procedure, NSVT was documented in 9 patients. Seven patients had new‐onset NSVT immediately postprocedure. At follow‐up, 4 of 9 patients who previously had NSVT preprocedure continued to have NSVT, 1 of 9 patients no longer had NSVT but had PVCs, and 4 of 9 patients no longer had NSVT. Among the patients with new‐onset NSVT postprocedure, 6 of 7 no longer had nonsustained VT, while 1 patient had PVCs. NSVT indicates nonsustained ventricular tachycardia; PVCs, premature ventricular contractions.
Figure 7
Figure 7
Isolated premature ventricular contractions (PVCs). Six patients had documented frequent isolated PVCs pre‐PPVI. Immediately postprocedure, there was resolution of PVCs in 4 (64%) patients, while 1 (17%) patient continued to have persistent PVCs, and 1 (17%) patient had nonsustained ventricular tachycardia (NSVT). Additionally, 8 patients had new‐onset PVCs immediately postprocedure. Seven out of 8 patients with new‐onset PVCs and both of the persistent PVCs postprocedure no longer had any arrhythmia at follow‐up. One patient with new‐onset PVCs and the patient with persistent PVCs immediately postprocedure continued to have PVCs at follow‐up. The patient with persistent PVCs throughout had an out‐of‐hospital sudden cardiac arrest. NSVT indicates nonsustained ventricular tachycardia; PPVI, percutaneous pulmonary valve implantation; PVCs, premature ventricular contractions.
Figure 8
Figure 8
Atrial fibrillation/atrial flutter (AF/AFL). Ten patients had documented AF/AFL pre‐PPVI. One patient had new‐onset AF/AFL immediately postprocedure. At follow‐up, 5 patients continued to have AF/AFL (4 preprocedure and 1 new onset), while 6 patients no longer had AF/AFL. AF/AFL indicates atrial fibrillation/atrial flutter; PPVI, percutaneous pulmonary valve implantation.
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