title: Outcomes after late reoperation in patients with repaired tetralogy of Fallot: the impact of arrhythmia and arrhythmia surgery.
abstract: BACKGROUND
  We evaluated outcomes in patients requiring late reoperation after tetralogy of Fallot (ToF) repair to identify risk factors for arrhythmia and determine whether arrhythmia surgery decreased the risk of subsequent death or recurrent arrhythmia.
  
  
  METHODS
  Review was performed of all ToF patients from 1969 to 2005 undergoing reoperation late (> 1 year) after repair. Patients with associated lesions, except pulmonary atresia, were included. A total of 249 patients had 278 reoperations. Procedures at initial reoperation included pulmonary valve replacement (PVR) in 217, ablation in 63, and tricuspid valve repair/replacement in 46. Pre-reoperative arrhythmias were present in 75, including supraventricular tachycardia (SVT) in 31, ventricular tachycardia (VT) in 34, and SVT+VT in 10 patients.
  
  
  RESULTS
  Median age at reoperation was 23 years (range, 1 to 63). Ten-year survival after reoperation was 93%, and was independent of arrhythmia status (p = 0.86). Arrhythmia patients were characterized by older age at initial repair and at late reoperation, tricuspid and pulmonary regurgitation, and longer QRS duration (p < 0.001 for all). Risk factors for post-reoperative recurrent arrhythmia were longer QRS duration and not having PVR. Longer QRS duration, with a cut-point of more than 160 msec, was associated with recurrent SVT (p = 0.004). Supraventricular tachycardia ablation improved arrhythmia-free survival (75% versus 33%, p < 0.001) but VT ablation did not (96% versus 95%, p = 0.50). However, recurrent VT occurred in only 3 patients (10%).
  
  
  CONCLUSIONS
  Late mortality in patients undergoing reoperation after ToF repair is not impacted by pre-reoperative arrhythmia. Prolongation of QRS identifies patients at risk for recurrent VT and SVT, but recurrent VT is uncommon. Early PVR, and surgical ablation in patients with SVT, decreases arrhythmic risk.
authors.affiliation: Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
authors.forename: Tara
authors.initials: T
authors.lastname: Karamlou
authors.forename: Ilana
authors.initials: I
authors.lastname: Silber
authors.forename: Robin
authors.initials: R
authors.lastname: Lao
authors.forename: Brian W
authors.initials: BW
authors.lastname: McCrindle
authors.forename: Louise
authors.initials: L
authors.lastname: Harris
authors.forename: Eugene
authors.initials: E
authors.lastname: Downar
authors.forename: Gary D
authors.initials: GD
authors.lastname: Webb
authors.forename: Jack M
authors.initials: JM
authors.lastname: Colman
authors.forename: Glen S
authors.initials: GS
authors.lastname: Van Arsdell
authors.forename: William G
authors.initials: WG
authors.lastname: Williams
mesh_terms: D000293:Adolescent; D000328:Adult; D001145:Arrhythmias, Cardiac / Q000453:epidemiology* / Q000601:surgery; D002648:Child; D002675:Child, Preschool; D015897:Comorbidity; D018618:Echocardiography, Doppler, Color; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D011664:Pulmonary Valve / Q000601:surgery; D012086:Reoperation; D012307:Risk Factors; D055502:Secondary Prevention; D013617:Tachycardia, Supraventricular / Q000453:epidemiology / Q000601:surgery; D013771:Tetralogy of Fallot / Q000453:epidemiology* / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome