Noninvasive Predictors of Ventricular Arrhythmias in Patients With Tetralogy of Fallot Undergoing Pulmonary Valve Replacement

Objectives: This study sought to test the hypothesis that a vectorcardiographic parameter, the QRS vector magnitude (QRSVm), can risk stratify those patients at risk for sustained spontaneous ventricular arrhythmias (VAs) or ventricular arrhythmia inducibility (VAI) in a large cohort of patients with tetralogy of Fallot (TOF). Background: Patients with TOF have an increased risk of VAs, but predicting those at risk can often be challenging. Methods: Blinded retrospective analyses of 177 TOF patients undergoing pulmonary valve replacement (PVR) between 1997 and 2015 were performed. VAI was evaluated by programmed electrical stimulation in 48 patients. QRS intervals and QRSVm voltage measurements were assessed from resting 12-lead electrocardiograms, and risk of VA was determined. Clinical characteristics, including imaging and cardiac catheterizations, were used for other modality comparisons. Results: Sustained spontaneous VA occurred in 12 patients and inducible VA in 18 patients. Age and QRSVm were significant univariate predictors of VA. QRSVm was the only independent predictor of VAI (p < 0.001). Using a root mean square QRS value of 1.24 mV, the positive and negative predictive values were 47.9% and 97.8%, respectively, for spontaneous sustained VA. For VAI, using a QRSVm cutoff of 1.31 mV, positive and negative predictive values were 63.0% and 95.3%, respectively. Conclusions: In TOF patients undergoing PVR, older age was associated with increased spontaneous VA risk. Lower QRSVm predicted spontaneous VA or VAI risk with high negative predictive values. QRSVm is the only independent predictor of VAI. These clinical features may help further risk stratify TOF patients requiring therapies to prevent sudden death.