Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Postoperative ventricular tachycardia in patients with congenital heart disease: diagnosis and management

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 469–476 (2008)Cite this article

Abstract

Ventricular tachycardia (VT) after palliative repair of congenital heart disease is relatively rare. Despite this rarity, VT is a known cause of early, intermediate and late morbidity and mortality in these patients. A number of factors have been linked to the development of VT in this unique patient population. The purpose of this article is to provide a concise overview regarding the etiology, diagnosis and treatment of VT in patients with congenital heart disease. In-depth information will be provided to aid diagnosis and the treatment of early postoperative VT. The use of additional diagnostic methods such as echocardiography, cardiac catheterization and electrophysiology studies to risk assess patients with postoperative VT will also be discussed. In addition, I examine the long-term management strategies for VT in these patients, from medical management and cardiovascular surgery to implantation of cardioverter-defibrillators.

Key Points

  • Ventricular arrhythmias can occur in all individuals who have undergone palliative surgery for congenital heart disease, and such arrhythmias are a significant source of early, intermediate and late morbidity and mortality

  • Familiarization with the patient's original anatomy, history of surgical repair or repairs, previous electrocardiograms, hemodynamic status and underlying rhythm is essential before diagnosing and treating ventricular tachycardia (VT)

  • For accurate diagnosis, VT must be distinguished from other cardiac dysrhythmias such as supraventricular tachycardia with bundle branch block

  • Echocardiography and/or cardiac catheterization can determine whether the patient has a hemodynamic issue

  • If a hemodynamic issue is found, and catheterization or surgery can be undertaken to correct the issue, then it is recommended the patient have a electrophysiology study at some point before hospital discharge

  • If the patient has 'normal' hemodynamics, the majority of electrophysiologists would recommend an electrophysiology study with aggressive ventricular stimulation—if VT is inducible then implantation of an implantable cardioverter-defibrillator is recommended; if VT is not induced, then close follow-up and consideration of medical management is required

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Wide complex tachycardia in a 16-year-old patient with d-transposition of the great arteries who underwent a Mustard procedure at 1 year of age.
Figure 2: Intra-atrial re-entry tachycardia as a cause of wide complex tachycardia.

Similar content being viewed by others

References

  1. Gatzoulis MA et al. (2000) Risk factors for arrhythmia and sudden cardiac death late after repair of tetralogy of Fallot: a multicentre study. Lancet 356: 975–981

    Article  CAS  Google Scholar 

  2. Deanfield JE et al. (1980) Detection of late arrhythmia and conduction disturbances after correction of tetralogy of Fallot. Br Heart J 44: 248–253

    Article  CAS  Google Scholar 

  3. Vetter VL and Horowitz LN (1982) Electrophysiologic residua and sequelae of surgery from congenital heart defects. Am J Cardiol 50: 588–604

    Article  CAS  Google Scholar 

  4. Webb Kavey RE et al. (1982) Incidence and severity of chronic ventricular dysrhythmias after repair of tetralogy of Fallot. Am Heart J 103: 342–350

    Article  Google Scholar 

  5. Garson A et al. (1972) Status of adult and adolescent after repair of tetralogy of Fallot. Circulation 59: 1232–1240

    Article  Google Scholar 

  6. Gillette PC et al. (1977) Sudden death after repair of tetralogy of Fallot: electrocardiographic and electrophysiologic abnormalities. Circulation 56: 566–571

    Article  CAS  Google Scholar 

  7. Blake RS et al. (1982) Conduction defects, ventricular arrhythmias and late sudden death after surgical closure of ventricular septal defect. Br Heart J 47: 305–315

    Article  CAS  Google Scholar 

  8. Snyder CS et al. (2007) Can pediatric electrophysiologists safely perform electrophysiology studies on adults with congenital heart disease? Ochsner J 7: 16–19

    PubMed  PubMed Central  Google Scholar 

  9. Walsh EP et al. (1988) Late results in patients with tetralogy of Fallot repaired during infancy. Circulation 77: 1062–1067

    Article  CAS  Google Scholar 

  10. Delaney JW et al. (2006) Acute postoperative arrhythmias after cardiac surgery in children. J Thorac and Cardiovasc Surg 131: 1296–1300

    Article  Google Scholar 

  11. Wessel H et al. (1980) Prognostic significance of arrhythmia in tetralogy of Fallot after intracardiac repair. Am J Cardiol 46: 843–848

    Article  CAS  Google Scholar 

  12. Fuster V et al. (1980) Long-term evaluation (12 to 22 years) of open heart surgery for tetralogy of Fallot. Am J Cardiol 46: 635–642

    Article  CAS  Google Scholar 

  13. Chandar J et al. (1990) Ventricular arrhythmias in postoperative tetralogy of Fallot. Am J Cardiol 65: 655–661

    Article  CAS  Google Scholar 

  14. Wita K et al. (2006) Incessant ventricular tachycardia in a patient with a severe aortic stenosis successfully treated by cardiac surgery. Kardiol Pol 64: 441–444

    PubMed  Google Scholar 

  15. Malhotra S et al. (2007) A case of congenitally corrected transposition of the great arteries with rare but life-threatening VT and a coincidental single coronary ostium. J Invasive Cardiol 19: 139–141

    Google Scholar 

  16. Snyder CS et al. (2007) Can pediatric electrophysiologists safely perform electrophysiology studies on adults with congenital heart disease? Ochsner J 7: 16–19

    PubMed  PubMed Central  Google Scholar 

  17. Janousek J et al. (1994) Atrial baffle procedures for complete transposition of the great arteries: natural course of sinus node dysfunction and risk factors for dysrhythmias and sudden death. Z Kardiol 83: 933–938

    CAS  PubMed  Google Scholar 

  18. Kugler J et al. (1983) Sustained ventricular tachycardia after repair of tetralogy of Fallot: new electrophysiological findings. Am J Cardiol 51: 1137–1143

    Article  CAS  Google Scholar 

  19. Denfield S et al. (1990) Growth in cardiac surgical scars with age: a canine model [abstract]. J Am Coll Cardiol 15: 176A

    Article  Google Scholar 

  20. Khairy P et al. (2008) Implantable cardioverter-defibrillators in tetralogy of Fallot. Circulation 117: 363–370

    Article  Google Scholar 

  21. Garson A et al. (1985) Prevention of sudden death after repair of tetralogy of Fallot: Treatment of ventricular arrhythmias. J Am Coll Cardiol 6: 221–227

    Article  Google Scholar 

  22. Zahka R et al. (1988) Long-term valvular function after total repair of tetralogy of Fallot: relation to ventricular arrhythmias. Circulation 78: III14–III19

    CAS  PubMed  Google Scholar 

  23. Berul C et al. (1997) Electrocardiographic markers of late sudden death risk in postoperative tetralogy of Fallot children. J Cardiovasc Electrophysiol 8: 1349–1356

    Article  CAS  Google Scholar 

  24. Gatzoulis M et al. (1995) Mechanoelectrical interaction in tetralogy of Fallot: QRS prolongation related to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation 92: 231–237

    Article  CAS  Google Scholar 

  25. Balaji S et al. (1997) QRS prolongation is associated with inducible ventricular tachycardia after repair of tetralogy of Fallot. Am J Cardiol 80: 160–163

    Article  CAS  Google Scholar 

  26. Garson A (1983) Arrhythmias. In The Electrocardiogram in Infants and Children: A Systematic Approach, 251–254 (Ed Garson A) Philadelphia: Lea and Febiger

    Google Scholar 

  27. Carboni M and Garson A (1998) Ventricular arrhythmias. In The Science and Practice of Pediatric Cardiology, edn 2, 2121–2168 (Eds Garson A. et al.) Baltimore: Williams and Wilkins

    Google Scholar 

  28. American Heart Association (2005) American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care of pediatric and neonatal patients: pediatric basic life support. Pediatrics 117: e989–e1004

  29. Garson A (1983) Effects of systemic alterations on the electrocardiogram. In The Electrocardiogram in Infants and Children: A Systematic Approach, 173–178 (Ed Garson A) Philadelphia: Lea and Febiger

    Google Scholar 

  30. American Heart Association (2000) The International Liaison Committee on Resuscitation: Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: an international consensus on science. Part 5. Pharmacology 1: agents for arrhythmias. Circulation 102: 1112–1128

  31. Kudenchuk P et al. (1999) Amiodarone for resuscitation after out-of-hospital cardiac arrest due to ventricular fibrillation. N Engl J Med 341: 871–878

    Article  CAS  Google Scholar 

  32. Drago F et al. (1998) Amiodarone used alone or in combination with propranolol: a very effective therapy for tachyarrhythmias in infants and children. Pediatr Cardiol 19: 445–449

    Article  CAS  Google Scholar 

  33. Yamawake N et al. (2007) Autonomic and pharmacological responses of idiopathic ventricular tachycardia arising from the left ventricular outflow tract. J Cardiovasc Electrophysiol 18: 1161–1166

    Article  Google Scholar 

  34. Johnson MS et al. (2006) Cardioversion of supraventricular tachycardia using lidocaine in five dogs. J Vet Intern Med 20: 272–276

    Article  Google Scholar 

  35. Khairy P et al. (2004) Value of programmed ventricular stimulation after tetralogy of Fallot repair: a multi center study. Circulation 109: 1994–2000

    Article  Google Scholar 

  36. Alexander M et al. (1999) Value of programmed ventricular stimulation in patients with congenital heart disease. J Cardiovasc Electrophysiol 10: 1045–1048

    Article  Google Scholar 

  37. Gonska B et al. (1996) Radiofrequency catheter ablation of right ventricular tachycardia late after repair of congenital heart defects. Circulation 94: 1902–1908

    Article  CAS  Google Scholar 

  38. Morwood J et al. (2004) Radiofrequency catheter ablation of ventricular tachycardia in children and young adults with congenital heart disease. Heart Rhythm 1: 301–308

    Article  Google Scholar 

  39. Stefanelli CB et al. (2002) Implantable cardioverter defibrillator therapy of life-threatening arrhythmias in young patients. J Interv Card Electrophysiol 6: 235–244

    Article  Google Scholar 

  40. Park JK and Pollock ME (1999) Use of an implantable cardioverter defibrillator in an eight-month-old infant with ventricular fibrillation arising from a myocardial fibroma. Pacing Clin Electrophysiol 22: 138–139

    Article  CAS  Google Scholar 

  41. Chevalier P et al. (1996) Symptomatic pericardial disease associated with patch electrodes of the automatic implantable cardioverter defibrillator: an underestimated complication? Pacing Clin Electrophysiol 19: 2150–2152

    Article  CAS  Google Scholar 

  42. Korte T et al. (1995) Incidence of ICD lead related complications during long-term follow-up: comparison of epicardial and endocardial electrode systems. Pacing Clin Electrophysiol 18: 2053–2061

    Article  CAS  Google Scholar 

  43. Kettering K et al. (2004) Long-term experience with subcutaneous ICD leads: a comparison among three different types of subcutaneous leads. Pacing Clin Electrophysiol 27: 1355–1361

    Article  Google Scholar 

  44. Cannon B et al. (2006) Innovative techniques for placement of implantable cardioverter-defibrillator leads in patients with limited venous access to the heart. Pacing Clin Electrophysiol 29: 181–187

    Article  Google Scholar 

  45. Snyder C et al. (2007) Minimally invasive implantation of a cardioverter-defibrillator in a small patient. J Thorac Cardiovasc Surg 133: 1375–1376

    Article  Google Scholar 

  46. Berul C et al. (2004) Minimally invasive cardioverter defibrillator implantation for children: an animal model and pediatric case report. Pacing Clin Electrophysiol 24: 1789–1794

    Article  Google Scholar 

Download references

Author information

Author notes

  1. Section of Pediatric Cardiology, 1514 Jefferson Highway, New Orleans, LA 70121, USA csnyder@ochsner.org

Authors and Affiliations

  1. CS Snyder is Head of Pediatric Electrophysiology at the Ochsner Clinic Foundation, New Orleans, LA, USA.,

    Christopher S Snyder

Authors
  1. Christopher S Snyder
    View author publications

    You can also search for this author in PubMed Google Scholar

Ethics declarations

Competing interests

The author declares no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Snyder, C. Postoperative ventricular tachycardia in patients with congenital heart disease: diagnosis and management. Nat Rev Cardiol 5, 469–476 (2008). https://doi.org/10.1038/ncpcardio1275

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpcardio1275

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing