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j.hrthm.2018.08.017

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Accepted Manuscript
Implant Techniques And Outcomes After Cardiac Resynchronization Therapy For
Congenitally Corrected Transposition of the Great Arteries
Jeremy P. Moore, MD, MS, David Cho, MD, MBA, Jeannette Lin, MD, Gentian Lluri,
MD, PhD, Leigh C. Reardon, MD, Jamil A. Aboulhosn, MD, Abbie Hageman, BS,
Kevin M. Shannon, MD
PII:
S1547-5271(18)30817-8
DOI:
10.1016/j.hrthm.2018.08.017
Reference:
HRTHM 7712
To appear in:
Heart Rhythm
Received Date: 11 March 2018
Please cite this article as: Moore JP, Cho D, Lin J, Lluri G, Reardon LC, Aboulhosn JA, Hageman
A, Shannon KM, Implant Techniques And Outcomes After Cardiac Resynchronization Therapy For
Congenitally Corrected Transposition of the Great Arteries, Heart Rhythm (2018), doi: 10.1016/
j.hrthm.2018.08.017.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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IMPLANT TECHNIQUES AND OUTCOMES AFTER CARDIAC
RESYNCHRONIZATION THERAPY FOR CONGENITALLY CORRECTED
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TRANSPOSITION OF THE GREAT ARTERIES
Authors: Jeremy P. Moore MD, MS,1,2 David Cho MD, MBA,3 Jeannette Lin MD,2
Hageman BS,4 and Kevin M. Shannon MD1,2
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Gentian Lluri MD, PhD,2 Leigh C. Reardon MD,2 Jamil A. Aboulhosn MD,2 Abbie
Total word count: 4,857
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Running title: Resynchronization therapy for congenitally corrected transposition
Affiliations: 1University of California Los Angeles, Department of Pediatric Cardiology
UCLA Medical Center, Division of Pediatric Cardiology, Los Angeles, CA; 2University of
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California Los Angeles, Ahmanson/UCLA Congenital Heart Disease Center,
Department of Medicine, Division of Cardiology, Los Angeles, CA; 3University of
California Los Angeles, Department of Medicine, Division of Cardiology, Los Angeles,
Angeles, CA.
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CA; 4David Geffen School of Medicine, University of California Los Angeles, Los
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Conflicts of interest: None
Author and address for correspondence:
Jeremy P. Moore MD, MS, FHRS
100 Medical Plaza Dr. Suite 770
Los Angeles, CA 90095
Email: jpmoore@mednet.ucla.edu,
P: (310) 267-6053; F: (310) 933-1728
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ABSTRACT
Background: Patients with congenitally corrected transposition of the great arteries
(CCTGA) are at risk for congestive heart failure (CHF). There are limited data on
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cardiac resynchronization therapy (CRT) techniques and long-term outcomes in this
population.
Objective: To determine implant techniques and efficacy of CRT for CCTGA
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Methods: A 15-year retrospective review of CCTGA patients undergoing CRT was
performed.
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Results: Twenty patients were identified (mean age 40.1 ± 15.3 years, baseline NYHA
class 2.0 [IQR 1.5 – 3.5]). Indication was pacing-induced ventricular dysfunction in 12,
AV block with anticipation for >40% ventricular pacing in 5, and intact AV conduction
with CHF and QRS prolongation in 3. A transvenous approach was successful in 18/19
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(95%) patients in whom it was attempted, with cannulation of a postero-septal ostium in
14, vein of Marshall in 2, and superior ectopic ostium in 2. Of 12 patients with baseline
CHF, there were 8 (67%) acute responders, with loss of response in 2 patients (median
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1.1 and 1.5 years, respectively). Only lead location in the right ventricular outflow tract
predicted poor CRT response (p=0.026). The QRS duration increased by 4.3 ms/year
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(p<0.001) despite stable pacing characteristics over time. CRT revision was required in
4 patients due to infection (2) or phrenic nerve capture (2), and was associated with loss
of CRT response in 1 patient.
Conclusions: A transvenous approach to CRT involving distinct coronary venous
patterns is feasible for most patients with CCTGA anatomy. Long-term outcome is
favorable, but characterized by return of RV dysfunction in some patients.
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KEY WORDS: congenital heart disease, congestive heart failure, heart transplantation,
systemic right ventricle, cardiac resynchronization therapy, congenitally corrected
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transposition of the great arteries
ABBREVIATIONS LIST: CCTGA, congenitally corrected transposition of the great
arteries; CHD, congenital heart disease; CRT, cardiac resynchronization therapy; CS,
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coronary sinus; CTA, computed tomographic angiograph; RA, right atrium; RV, right
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ventricle
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BACKGROUND:
Adult patients with congenitally corrected transposition of the great arteries (CCTGA)
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are at an elevated risk for progressive congestive heart failure (CHF) with age.1, 2 While
cardiac resynchronization therapy (CRT) is associated with a reduction in heart failure
and all-cause mortality among patients with severe systemic LV dysfunction and QRS
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prolongation or chronic ventricular pacing,3, 4 to date, similar data do not exist for
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patients with CCTGA.
Isolated series and larger heterogeneous studies containing various congenital heart
disease (CHD) lesions have generally demonstrated favorable acute outcomes after
CRT for patients with a failing systemic RV, but with only a subset characterized by
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CCTGA anatomy. Many considerations remain ill-defined in the CCTGA population,
including implant technique and relevant coronary venous anatomy,5-10 optimal lead
position,11, 12 long-term follow-up after initial CRT response,5-7, 13 and predictors of
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positive clinical response.5, 7, 8, 12, 13 In addition, reports to date have included a
significant number of patients undergoing CRT lead placement by surgical rather than
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transvenous approach, in part due to the presumed technical challenges associated
with CCTGA anatomy.5
The present study sought to clarify some of the gaps in the current understanding of
CRT for CCTGA. In particular, it was hypothesized that distinct anatomical coronary
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sinus (CS) variants would exist and would be amenable to a transvenous approach, and
that clinical parameters noted at the time of implant could predict CRT outcomes.
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METHODS:
After institutional review board approval, the Ahmanson/UCLA Adult Congenital Heart
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Disease electrophysiology database was searched for all consecutive patients
undergoing attempted CRT between March 2002 and March 2018. Patients were
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included if the congenital anatomy was deemed to be biventricular with the systemic
chamber of RV morphology with both atrioventricular (AV) and ventriculoarterial
discordance.
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Baseline variables of interest included demographic data, underlying cardiac diagnosis,
New York Heart Association (NYHA) functional class and history of supraventricular
arrhythmia. Echocardiographic data was reviewed and systemic RV function was
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graded as mild, moderately, or severely depressed and quantified by fractional area of
change (FAC). Other measures of RV systolic function, including RV basal and long-
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axis shortening, RV myocardial performance, and systolic annular motion were also
recorded. Likewise, AV valve regurgitation was classified semi-quantitatively as mild,
moderate, or severe. The preoperative electrocardiogram was reviewed for rhythm and
duration of the QRS complex. The indication for CRT was classified as 1) CHF with
intact AV conduction and QRS prolongation, 2) cardiomyopathy related to chronic left
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ventricular (LV) pacing or 3) complete AV block with anticipation of >40% ventricular
pacing.14
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Procedural data
According to institutional practice, all patients with the diagnosis of CCTGA at the
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Ahmanson/UCLA Adult Congenital Heart Disease Center were initially referred for CRT
lead placement by the transvenous approach. In the early experience, selective
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coronary angiography alone was performed during the implant procedure to evaluate
coronary venous drainage. Later, preoperative CT angiography (CTA) was routinely
performed in order to more clearly demonstrate the coronary venous anatomy in
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advance of the procedure.
Device implantation was performed under general anesthesia with endotracheal
intubation after the patient had provided informed consent. After selective coronary
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angiography with levophase filling of the coronary venous anatomy, access to the
subclavian vein was obtained, the CS ostium was cannulated with a luminal decapolar
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catheter (Abbott Medical, St. Paul, Minnesota) and a sheath advanced into the CS. For
patients without conventional coronary venous drainage, access to the ectopic coronary
ostium was obtained with the use of a variety of preformed catheters and guidewires,
after which the delivery sheath and dilator were advanced over the wire into the ectopic
vein. Once venous access had been obtained, wedge venography was routinely applied
to outline the anatomy in its entirety.
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All stored procedural venograms, post-operative chest radiographs and CT studies were
independently reviewed by 2 electrophysiologists in order to classify the type of venous
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drainage and the final CRT lead position. Coronary venous drainage was classified as
1) conventional, when a dominant main body of the CS arose from the postero-septal
right atrium (RA) without a significant (<1 mm) accessory ostium; 3) dual ostia, when 2
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closely-spaced CS ostia were encountered but arose separately from the right posteroseptal space; 3) separate ostia, when both a postero-septal CS ostium was
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encountered in addition to a dominant accessory ostium from the superior RA near the
RA appendage; and 4) vein of Marshall-dependent, when all coronary venous drainage
occurred by way of a vein of Marshall to the innominate vein, with or without an
additional, oftentimes diminutive accessory superior RA venous ostium. See figure 1 for
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examples of CS anatomy types. The final lead position was categorized as located
within the RV body versus RV outflow tract. For leads in the RV body, the position was
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Outcomes
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additionally categorized as basal, mid, or apical.
CRT response was defined as sustained improvement in NYHA class by ≥1 grade or an
increase in RV FAC ≥10% within 3 months of CRT for patients with baseline NYHA
class ≥2.9 Measured variables were obtained on a repeated basis at the time of routine
outpatient evaluation, with a frequency determined at the discretion of the treating
cardiologist. The primary outcome was considered to be CRT failure, defined as either
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1) lack of acute CRT response or 2) return of NYHA class <1 point from baseline during
the follow-up period. Secondary outcomes included changes in QRS duration and
and death or heart transplantation during follow up.
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Statistical analysis
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echocardiographic indices following CRT, rate of change in the QRS duration over time,
Descriptive statistics are presented as counts and percentages for categorical variables
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and median (interquartile range [IQR]) or mean ± standard deviation as appropriate.
Continuous data were compared using Wilcoxon rank-sum tests and comparisons
between categorical variables were performed using Chi-square or Fisher’s exact test.
Predictors of CRT failure were assessed by univariable Cox proportional hazards
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modeling. Prespecified covariates included age, implant indication, acute change in
QRS duration following CRT, history of atrial tachyarrhythmia (AT), need for CRT
system revision, and lead placement in the RVOT versus the RV body. The results were
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then corrected by the Holm procedure for multiple hypothesis tests.15 To assess the
longitudinal rate of change in QRS duration following CRT, and to explore the
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association between QRS duration and the endpoint of death or heart transplantation
during follow-up, a mixed effects model was constructed where time was considered a
fixed effect and the patient as a random effect. The composite of death or heart
transplantation was entered as a fixed effect and as an interaction term with time. The
rate of change of QRS duration over time was reported as a slope estimate. Statistical
analyses were performed using JMP version 13.0 (Cary, NC). P-values <0.05 are
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considered statistically significant.
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RESULTS:
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Clinical characteristics
A total of 20 patients with CCTGA undergoing CRT were identified (mean age 40 ± 15
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years) and are shown in Table 1. The median baseline NYHA class was 2.0 (IQR 1.5 –
3.5; NYHA class ≥2 in 12 [60%] patients) with baseline QRS duration 172 ms (134 –
184 ms). Four patients (20%) were listed for heart transplantation, and one patient
presented with cardiogenic shock at the time of referral for CRT. The indication for CRT
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was pacing-induced ventricular dysfunction in 12, complete AV block with anticipation
for >40% ventricular pacing in 5, and CHF with intact AV conduction and QRS
prolongation in 3. There was a history of AT in 10 patients, and this was observed at the
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time of CRT in 6 (atrial fibrillation in 3, multiple coexisting ATs in 2, intra-atrial reentrant
tachycardia in 1). In 1 case, CRT was performed in anticipation of possible AV node
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ablation for refractory AT.
Technical considerations for CCTGA anatomy
All patients with CCTGA except one underwent attempts at transvenous lead placement
for CRT, with procedural success in 18 (95%). A single patient underwent primary
epicardial lead placement at an outside institution, but subsequently received clinical
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care locally and was included in the study. Attempts at lead placement failed in one
patient with a diminutive postero-septal CS. This patient was then referred for epicardial
CRT due to refractory symptomatic heart failure in lieu of heart transplantation. The
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coronary venous anatomy for the 19 patients with attempted CRT placement was
conventional in 7 (37%), separate ostia in 7 (37%), dual ostia in 3 (16%) and vein of
Marshall-dependent in 2 (10%). Despite the variability in anatomic origins, all except 4
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of the 18 (22%) transvenous leads were ultimately delivered via a postero-septal CS
ostium. Two patients with separate ostia underwent cannulation of a superior CS
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ostium, and 2 patients with vein of Marshall-dependent anatomy underwent placement
of the lead from the innominate vein (Figures 2 and 3).
The final lead position was within the RV body in 12 patients and RVOT in 8. There was
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a greater proportion of RVOT lead placement in patients with separate ostial anatomy
versus other CS patterns (p=0.041). The final lead position was judged to be basal in 6,
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Outcomes
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mid-RV free wall in 5, and apical in 1 patient.
There were no acute procedural complications and no lead dislodgements. Following
CRT, the median QRS duration decreased by 18 ms (IQR -38 to +14 ms). The change
in QRS duration varied by implant indication (p<0.001) with decreases noted for implant
indications other than AV block and anticipation for >40% LV pacing (Figure 4A).
Likewise, although echocardiographic indices of RV systolic function were not
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significantly different following CRT for the overall population, significant improvement in
fractional area of change was noted when excluding patients referred for AV block
(Table 2). Following CRT, there was a gradual increase in QRS duration over time
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(slope 4.3 ms per year, p<0.001, Figure 4B), with a greater rate of change associated
with the composite of death or heart transplantation (slope difference 1.9 ms per year,
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p<0.001).
Of 12 patients with NYHA class ≥2 at the time of CRT, there were 4 non-responders
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(67%). Of these, 2 were referred for complete AV block. The first presented with postpartum cardiogenic shock and died from end-organ failure despite successful CRT. The
second experienced NYHA class II heart failure that only partially improved following
CRT owing to ongoing AT and inability to provide AV sequential pacing. Two additional
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patients were referred for CRT after the development of pacing-induced
cardiomyopathy. The first was affected by severe LV-to-pulmonary artery conduit
obstruction and NYHA class IV symptoms, experiencing resolution of symptoms only
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after surgical conduit revision. The second patient presented with atrial fibrillation and
decompensated heart failure and developed progressive perivalvular tricuspid
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regurgitation despite successful CRT. Among the 4 patients listed for heart
transplantation, 3 improved and were removed from the transplant list, whereas the
patient with AF and perivalvular tricuspid regurgitation noted above died from end-stage
heart failure.
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During a median follow-up of 4.6 years (IQR 0.4 – 11.5 years), loss of initially favorable
CRT response occurred in 2 patients at 1.1 and 1.5 years, respectively. The first
developed loss of response following extraction of an infected transvenous CRT system
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and implantation of an epicardial dual chamber device, ultimately succumbing to
progressive heart failure. The second developed intractable symptoms associated with
a multifocal AT, requiring AV node ablation. Of the prespecified covariates, only lead
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location at the RV free wall was associated with sustained CRT response (HR 0.14,
95% CI 0.01 – 0.97 for RV free wall versus RV outflow tract and CRT failure; p=0.026.
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Overall, revision of a CRT system was necessary in 4 (20%) patients. This involved
repositioning of a CS lead in 2 due to phrenic nerve capture and conversion to an
epicardial system in 2 others due to infection (endocarditis in 1, pocket infection in 1).
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For the 8 patients who were asymptomatic at the time of CRT implantation, one patient
developed CHF and underwent heart transplantation 12 years later. The remaining 7
years after CRT.
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DISCUSSION:
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patients were minimally symptomatic (median NYHA class 1.5) at last follow-up 7.7
This is the first study of CRT for patients with CCTGA anatomy focusing on the
technical considerations for lead implantation and long-term outcomes. Key findings
from this experience include the observation that CS anatomy, although variable, often
lends itself to successful transvenous lead placement. In addition, there was a positive
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acute response of 67% that persisted for the majority of patients during the follow-up
period of 4.6 years.
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To date, there is limited data on CRT characteristics in patients with CCTGA anatomy.
Mostly heterogeneous studies of congenital heart disease patients have reported
improvement of the systemic RV with CRT,6, 9, 16 while others have suggested a more
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disappointing prognosis.12, 17 The present study is unique in that it involved a
predominantly transvenous approach and focused exclusively on CCTGA, providing
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complete data regarding coronary venous anatomy, implant strategies, and long-term
outcomes. This experience suggests that many of the perceived obstacles to
transvenous CRT can be overcome by careful attention to the unique anatomical
variations encountered in this population, and in most cases a surgical approach can be
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avoided.
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Coronary venous anatomy in CCTGA
The CS ostium and venous tributaries are known to be abnormal in patients with
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CCTGA, which can create difficulty in venous cannulation. In one of the largest
postmortem studies to date, Bottega and colleagues performed methodological gross
evaluation of the cardiac veins in a series of 51 hearts.18 In these authors’ experience, a
normal CS ostium and proximal course was observed in 88% of pathologic cases,
similar to the 17 patients with 1 or more CS ostia in the normal location in the present
study. The present angiographic variations also correlate well with these prior
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anatomical descriptions. For instance, 2 separate CS openings, atresia of the CS, and a
superior ectopic ostium have been previously described and were observed in this
series.18 This investigation however, also provides additional clinical data on the course,
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distribution and implications of the coronary veins in CCTGA. In particular, it was
observed that a superior cardiac vein frequently originates from the base of the right
atrial appendage with an anterior and leftward course towards the free wall of the RV
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outflow tract. This unusual venous system appears to provide at least partial drainage
from the muscular outflow tract for most patients (Figure 1). Cannulation of this superior
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system may be difficult, and was only utilized for lead placement in 2 cases but was
useful for a more complete evaluation of the coronary veins in 2 others. Finally,
drainage via the vein of Marshall is an interesting and novel observation. Although not
initially suspected, the presence of this connection could be discovered with the use of
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systematic venography and represented a favorable target for CRT.
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Outcomes of cardiac resynchronization for CCTGA
The long-term outcome after CRT for patients with CCTGA anatomy remains
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incompletely understood. Although previous reports have described a favorable acute
response for most patients with systemic RVs, clinical follow-up has generally ranged
from only 4 – 17 months.5, 6, 9, 11-13, 16, 17 Given that these patients may be inherently
predisposed to progressive ventricular failure, the long-term status even after a
favorable acute response may not necessarily be positive. The results of this study are
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consistent with this hypothesis, and suggest that recurrent heart failure may
occasionally develop despite initial benefit.
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It has been suggested that for patients with systemic RV failure, lead placement in the
outflow tract11 may be superior to the basal or the mid-RV free wall.5, 13, 16 In the present
group of patients, the RV outflow tract was only targeted in an attempt to achieve
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maximum inter-lead anatomic distance19 or because no other suitable transvenous
location could be found. Interestingly, RVOT location was the only predictor of poor
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outcome among the covariates tested in the present study. It is conceivable that lead
locations targeting the outflow tract may be inferior to those placed at the RV free wall
despite late activation and apparent shortening of the QRS duration, because the
systemic RV relies primarily on circumferential rather than longitudinal shortening in the
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setting of chronic pressure overload.20 Unfortunately, there were insufficient data to
determine if this was an independent predictor of CRT failure, since these patients were
often affected by other hemodynamic and rhythm disorders that could also have had a
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negative impact on outcome.
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Importantly, patients undergoing new device implant with the indication of complete AV
block displayed more negative characteristics early after CRT than other patients in this
study. These patients showed less improvement in RV systolic function as measured by
fractional area change on the post-procedure echocardiogram, and exhibited a uniform
increase in QRS duration following CRT. These findings did not translate into worse
clinical outcomes in the context of this study, however it appears that this group might
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ultimately be more vulnerable to a progressive decline in functional status following
CRT. As these patients typically demonstrate narrow complex junctional escape rhythm
prior to CRT, these findings are not surprising. The alternative of His bundle pacing in
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this subgroup may ultimately prove to be a superior approach for the reproduction of
intrinsic conduction.
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Finally, QRS duration was found to increase gradually following CRT despite stable
pacing characteristics in almost all patients. This interesting finding likely relates to an
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ongoing process of myocardial failure over time.1 Indeed, patients with more rapid
progression of QRS widening following CRT implantation were more likely to experience
the composite of death or heart transplantation versus those with more gradual
increases. Serial observation of QRS duration may therefore prove to be a useful
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LIMITATIONS:
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clinical marker for the evaluation of the systemic RV patient following CRT.
This study was primarily limited by its retrospective design and sample size. As CRT
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was performed over a 15-year period, details of the timing of the local electrogram at
the CRT lead site, measures of dyssynchrony, cardiopulmonary exercise test values,
and contemporary biomarkers were not routinely available. The study was also largely
exploratory, therefore only prespecified statistical tests were performed in order to
determine predictors of only the most clinically-relevant endpoints. Still, this study
provides a novel contribution to the understanding and long-term CRT management for
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patients with CCTGA, providing data on implant characteristics and outcomes in this
important population.
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CONCLUSIONS:
A transvenous approach to CRT is feasible in the majority of patients with CCTGA
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anatomy, with distinct coronary venous subtypes. The long-term outcome appears to be
favorable, but is characterized by a late return of heart failure in some patients. Those
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with worsening electrocardiographic response appear to experience poorer outcomes
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during follow-up.
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Acknowledgements: None
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TABLES
Table 1. Baseline CCTGA population characteristics
40 ± 15
10 (50)
4 (21)
1 (5)
16 (80)
5 (25)
3 (15)
5 (25)
172 (134 - 184)
2 (2 - 3)
24 (15-31)
63 (57-65)
1 (1-2)
0 (0 - 1)
20 (12 - 21)
4 (20)
3 (15)
12 (60)
5 (25)
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Age
Gender, male
Dextrocardia
Situs inversus
AV block
Previous CIED
Transvenous pacemaker
Epicardial pacemaker
Transvenous ICD
Baseline QRS, ms
NYHA class
RV FAC, %
LV EF, %
Tricuspid regurgitation
Mitral regurgitation
Peak VO2
Listed for heart transplant
CRT indication
RV dysfunction, QRS prolongation
Spontaneous conduction
Chronic LV pacing
New device, >40% pacing
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CCTGA n=20
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Baseline characteristics
Abbreviations: AV, atrioventricular; CIED, cardiac implanted electronic device; CCTGA,
congenitally corrected transposition of the great arteries; ICD, implantable cardioverterdefibrillator; NYHA, New York Heart Association; RV, right ventricle; LV, left ventricle;
FAC, fractional area of change; EF, ejection fraction; VO2, oxygen consumption; CRT,
cardiac resynchronization therapy.
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Table 2. Echocardiographic indices before and after CRT
27 (23-36)
58 (55-63)
4.8 (3.7-5.6)
6.3 (5.6-7.7)
0.6 (0.5-0.70
6 (6.0-10.5)
1 (0.5-1)
0 (0-1)
0.166
0.433
0.83
0.817
0.794
0.512
0.156
0.211
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24 (15-31)
63 (57-65)
4.7 (4.3-5.2)
6.7 (5.9-7.7)
0.6 (0.3-0.8)
8 (6.8-9.8)
1 (1-2)
0 (0-1)
p-value
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RV fractional area of change
LV ejection fraction
RV basal shortening
RV long axis shortening
RVMPI
S’ velocity
Tricuspid regurgitation
Mitral regurgitation
Post
Exclusion of AV block as CRT indication*
Pre
Post
p-value
22 (14-28)
63 (58-63)
4.7 (4.3-5.2)
6.7 (5.7-8)
0.6 (0.4-0.8)
8 (6.5-8.5)
1 (0.5-2)
0 (0-1)
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All patients
Pre
27(23-34)
58 (55-63)
5.0 (3.7-5.7)
6.2 (5.6-7.8)
0.7 (0.7-0.7)
6 (6-9)
1 (0-1)
0 (0-0.8)
0.048
0.43
0.5
0.628
0.317
0.368
0.202
0.244
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Abbreviations: CRT, cardiac resynchronization therapy; LV, left ventricle; RV, right ventricle; MPI, myocardial performance
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index; S, systolic annular excursion. *See text.
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FIGURE LEGENDS
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Figure 1. Variants of coronary venous anatomy in CCTGA. The systemic RV is shown in
a modified left anterior oblique view with the coronary sinus shaded in blue. For ease of
comparison, both situs inversus and dextrocardic hearts are shown in their
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corresponding l-looped and levocardic positions. Circles represent the final position of
the pacing cathode (small = basal, medium = mid-ventricular, large = apical position) for
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the 18 patients undergoing a successful transvenous approach. Blue circles represent
patients who failed to respond to CRT (4) or who developed recurrent symptoms during
follow-up (2).
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Figure 2. A) Twenty-eight-year-old male with CCTGA, cardiac segments {I,D,D} and
complete AV block referred for heart transplantation. The patient had a prior right sided
transvenous pacemaker with partial lead removal. During the CRT procedure, an
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ectopic superior CS ostium (white arrow) from the base of the morphologic right atrial
appendage was targeted. The lead tip (black arrow) is in the inferior aspect right
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ventricular outflow tract. Following CRT, the heart failure resolved and he was de-listed
from heart transplantation.
Figure 3. Forty-five-year-old male with CCTGA and NYHA class III heart failure with
attempted CRT at a referring institution. A) Serial panels show the approach for lead
placement via a vein of Marshall. Panels: a) Anterior-posterior and b) lateral view of a
superior ostium draining to the RA appendage, initially noted after selective coronary
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angiography; c) wedge injection of coronary venous anatomy; d) drainage continues
superiorly via the vein of Marshall; e) subsequent cannulation of Marshall’s vein; and f)
lead placement in a postero-lateral venous branch. There was atresia of the typical
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ostium at the postero-septal RA. B) Post-procedure posterior-anterior and lateral
radiographs demonstrating final CRT lead position. White arrow points to entrance into
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the vein of Marshall and black arrow to the lead tip.
Figure 4. A) QRS duration before and after CRT, grouped by device indication with
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medians in bold text. Blue circles represent patients who failed to respond acutely to
CRT or who developed recurrent symptoms during follow-up. The QRS duration varied
significantly by pacing indication with decreases noted for patients with chronic LV
pacing and intact AV conduction. AV = atrioventricular, ms = milliseconds; LV = left
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ventricle. *Pre- and/or post-CRT ECG unavailable in 2 patients. B) Scatterplot of QRS
duration following CRT over time. Black lines represent patients who died or required
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heart transplantation during follow-up. See text for further details.
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REFERENCES
6.
7.
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9.
10.
11.
12.
13.
14.
15.
16.
17.
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5.
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2.
Graham TP, Jr., Bernard YD, Mellen BG, et al. Long-term outcome in congenitally corrected
transposition of the great arteries: a multi-institutional study. J Am Coll Cardiol Jul 2000;36:255261.
Piran S, Veldtman G, Siu S, Webb GD, Liu PP. Heart failure and ventricular dysfunction in patients
with single or systemic right ventricles. Circulation Mar 12 2002;105:1189-1194.
Curtis AB, Worley SJ, Adamson PB, Chung ES, Niazi I, Sherfesee L, Shinn T, Sutton MS,
Biventricular versus Right Ventricular Pacing in Heart Failure Patients with Atrioventricular Block
Trial I. Biventricular pacing for atrioventricular block and systolic dysfunction. N Engl J Med Apr
25 2013;368:1585-1593.
Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of
heart-failure events. N Engl J Med Oct 1 2009;361:1329-1338.
Janousek J, Tomek V, Chaloupecky VA, Reich O, Gebauer RA, Kautzner J, Hucin B. Cardiac
resynchronization therapy: a novel adjunct to the treatment and prevention of systemic right
ventricular failure. J Am Coll Cardiol Nov 2 2004;44:1927-1931.
Dubin AM, Janousek J, Rhee E, et al. Resynchronization therapy in pediatric and congenital heart
disease patients: an international multicenter study. J Am Coll Cardiol Dec 20 2005;46:22772283.
Kakavand B, Douglas WI, Manfredi JA, Di Sessa TG. Successful management of acute failure of
the systemic right ventricle with cardiac resynchronization therapy. Pediatr Cardiol Sep-Oct
2006;27:612-613.
Saxon LA, Olshansky B, Volosin K, et al. Influence of left ventricular lead location on outcomes in
the COMPANION study. J Cardiovasc Electrophysiol Jul 2009;20:764-768.
Janousek J, Gebauer RA, Abdul-Khaliq H, et al. Cardiac resynchronisation therapy in paediatric
and congenital heart disease: differential effects in various anatomical and functional
substrates. Heart Jul 2009;95:1165-1171.
Koyak Z, de Groot JR, Krimly A, et al. Cardiac resynchronization therapy in adults with congenital
heart disease. Europace Feb 1 2018;20:315-322.
Miyazaki A, Sakaguchi H, Kagisaki K, Tsujii N, Matsuoka M, Yamamoto T, Hoashi T, Noda T,
Ohuchi H. Optimal pacing sites for cardiac resynchronization therapy for patients with a
systemic right ventricle with or without a rudimentary left ventricle. Europace Jan 2016;18:100112.
Kiesewetter C, Michael K, Morgan J, Veldtman GR. Left ventricular dysfunction after cardiac
resynchronization therapy in congenital heart disease patients with a failing systemic right
ventricle. Pacing Clin Electrophysiol Feb 2008;31:159-162.
Cowburn PJ, Parker JD, Cameron DA, Harris L. Cardiac resynchronization therapy: retiming the
failing right ventricle. J Cardiovasc Electrophysiol Apr 2005;16:439-443.
Khairy P, Van Hare GF, Balaji S, et al. PACES/HRS Expert Consensus Statement on the
Recognition and Management of Arrhythmias in Adult Congenital Heart Disease: Executive
Summary. Heart Rhythm 2014;11:e81-e101.
Holm S. A Simple Sequentially Rejective Multiple Test Procedure. Scandinavian Journal of
Statistics 1979;6:65-70.
Jauvert G, Rousseau-Paziaud J, Villain E, Iserin L, Hidden-Lucet F, Ladouceur M, Sidi D. Effects of
cardiac resynchronization therapy on echocardiographic indices, functional capacity, and clinical
outcomes of patients with a systemic right ventricle. Europace Feb 2009;11:184-190.
Cecchin F, Frangini PA, Brown DW, Fynn-Thompson F, Alexander ME, Triedman JK, Gauvreau K,
Walsh EP, Berul CI. Cardiac resynchronization therapy (and multisite pacing) in pediatrics and
AC
C
1.
23
ACCEPTED MANUSCRIPT
RI
PT
SC
M
AN
U
TE
D
20.
EP
19.
AC
C
18.
congenital heart disease: five years experience in a single institution. J Cardiovasc Electrophysiol
Jan 2009;20:58-65.
Bottega NA, Kapa S, Edwards WD, Connolly HM, Munger TM, Warnes CA, Asirvatham SJ. The
cardiac veins in congenitally corrected transposition of the great arteries: delivery options for
cardiac devices. Heart Rhythm Oct 2009;6:1450-1456.
Stabile G, D'Onofrio A, Pepi P, et al. Interlead anatomic and electrical distance predict outcome
in CRT patients. Heart Rhythm Nov 2015;12:2221-2229.
Pettersen E, Helle-Valle T, Edvardsen T, Lindberg H, Smith HJ, Smevik B, Smiseth OA, Andersen K.
Contraction pattern of the systemic right ventricle shift from longitudinal to circumferential
shortening and absent global ventricular torsion. J Am Coll Cardiol Jun 26 2007;49:2450-2456.
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