Utility of Cardiac Magnetic Resonance Imaging in Predicting Atrial Arrhythmias in Repaired Tetralogy of Fallot

https://doi.org/10.1016/j.amjcard.2022.03.043Get rights and content

Arrhythmias are the leading cause of morbidity and mortality in repaired tetralogy of Fallot (TOF), and over 20% of these patients will develop a sustained atrial arrhythmia during their lifetimes. Cardiac magnetic resonance imaging (cMRI) is frequently performed in TOF, although its ability to identify patients at risk of atrial arrhythmias is uncertain. Adult TOF patients (n = 175) with no history of atrial arrhythmia who underwent cMRI between 2003 and 2020 at a single tertiary care center were identified. Clinical characteristics and imaging findings were evaluated to identify a predilection for atrial arrhythmias using Kaplan–Meier survival analysis and log-rank testing. Multivariable Cox regression was used to determine independent predictors of atrial arrhythmias. Over a median follow-up of 3.6 years, 29 patients (17%) developed atrial arrhythmias. Independent predictors of atrial arrhythmia included age (hazard ratio [HR] 1.06 per 1-year increase, 95% confidence interval [CI] 1.02 to 1.09, p = 0.002), diabetes mellitus (HR 4.26, 95% CI 1.26 to 14.41, p = 0.020), indexed right ventricular end-diastolic volume (RVEDVi), (HR 1.20 per 10-ml/m2 increase, 95% CI 1.05 to 1.39, p = 0.010), and moderate or greater tricuspid regurgitation (TR) (HR 6.32, 95% CI 2.15 to 18.60, p = 0.001). Utilizing Kaplan–Meier analysis, patients with at least mild right ventricular dilation (RVEDVi >100 ml/m2, p = 0.047) and greater than or equal to moderate TR (p <0.001) were found to be significantly more likely to develop atrial arrhythmias. In conclusion, cMRI can help to identify TOF patients at increased risk for atrial arrhythmia beyond standard clinical and imaging data by better quantifying RVEDVi and degree of TR.

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Methods

Patients ≥18 years of age with repaired TOF and no history of atrial arrhythmias who underwent cMRI performed between 2003 and 2020 were identified from a single tertiary US hospital (Duke University Medical Center, Durham, North Carolina) database. The first cMRI obtained at our center as an adult was generally considered the index cMRI, unless the images were inadequate for full analysis, in which case the first adequate scan was utilized.

Demographics (age at index cMRI, gender, race, and

Results

In total, 175 patients with repaired TOF who had undergone index cMRI at ≥18 years of age with no history of atrial arrhythmias were identified. Median age at time of initial surgical TOF repair was 3.1 years, and median age at the time of index cMRI was 33.7 years. Demographic, clinical, and surgical data of the study population are summarized in Table 1 and cMRI data in Table 2.

Over a median follow-up of 3.6 years, 29 patients (17%) developed atrial arrhythmias, including 15 with atrial

Discussion

This study identified age, RVEDVi, degree of TR, and diabetes mellitus as predictors of atrial arrhythmia development in repaired TOF. Among previous studies that have assessed cMRI metrics associated with atrial arrhythmias in this population, results are varied.1,8,12, 13, 14, 15 Studies with at least 20 outcomes that examined patients with no history of arrhythmias have either displayed no association between RV size and an isolated outcome of atrial arrhythmia development, or failed to

Disclosures

Dr. Spector received consulting fees from Janssen Research and Development. Dr. Campbell receives consulting fees from Longeveron Inc. Dr. Krasuski receives consulting fees from Actelion Pharmaceuticals and Gore Medical, and research funding from the Adult Congenital Heart Association, Actelion Pharmaceuticals, Corvia, CryoLife, Edwards Lifesciences, and Medtronic. The remaining authors have no conflicts of interest to declare.

Funding

None.

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