Ventricular Arrhythmias and Sudden Death Following Percutaneous Pulmonary Valve Implantation in Pediatric Patients

Abstract

Reports have suggested a transient increase in ventricular ectopy early after percutaneous pulmonary valve implantation (PPVI). Little is known about the potential for more serious ventricular arrhythmias (VA) in children who undergo PPVI. We sought to evaluate the incidence of severe VA following PPVI in a pediatric population and to explore potential predictive factors. A retrospective cohort study was conducted of patients who underwent PPVI under 20 years of age in our institution from January 2007 to December 2019. The primary outcome of severe VA was defined as sustained and/or hemodynamically unstable ventricular tachycardia (VT), inducible sustained VT, or sudden death of presumed arrhythmic etiology. A total of 21 patients (mean age 16.2 ± 2.1 years; 66.7% male) underwent PPVI. The majority of patients (N = 15; 71.4%) had tetralogy of Fallot (TOF) or TOF-like physiology, with the most common indication being pulmonary insufficiency (N = 10; 47.6%). During a median follow-up of 29.6 months (IQR 10.9-44.0), severe VA occurred in 3 (14.3%) patients aged 15.6 (IQR 14.7-16.1) a median of 12.3 months (IQR 11.2-22.3) after PPVI. All events occurred in patients with TOF-like physiology following Melody valve implant. In conclusion, severe VA can occur long after PPVI in a pediatric population, particularly in those with TOF-like physiology. Further studies are required to elucidate underlying mechanisms and assess strategies to mitigate risks.

Keywords: Children; Congenital heart disease; Pediatrics; Pulmonary valve replacement; Tetralogy of Fallot; Ventricular arrhythmia.

Fig. 1

A Three models of percutaneous valve implanted in the pulmonary position in our population: the Melody® valve (left panel, reproduced with permission from Medtronic Inc), the Edwards Sapien® valve (middle panel, reproduced with permission from Edwards Inc) and the Venus P-valve® (right panel, reproduced with permission from Medtech). B 12-lead ECG recorded in patient #1 who presented to the emergency department for sustained palpitations and demonstrating spontaneous monomorphic ventricular tachycardia (cycle length 250 ms). C 12-lead ECG recorded in patient #2 during programmed ventricular stimulation. A rapid sustained monomorphic ventricular tachycardia (cycle length 200 ms) was induced during apical right ventricular pacing at a drive train of 600 ms with three extra-stimuli