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Intraoperative Conduction Mapping in Complex Congenital Heart Disease
Quick Takes
- Intraoperative His bundle mapping is safe and required a median mapping time of 6 minutes.
- Postoperative atrioventricular block requiring pacemaker (AVB/PM) frequency was significantly reduced with mapping in patients with heterotaxy and those without L-malposed great arteries.
Study Questions:
What is the impact of intraoperative His bundle (HB) mapping during complex biventricular congenital heart disease (CHD) repair on postoperative atrioventricular block requiring pacemaker (AVB/PM)?
Methods:
A retrospective cohort study was performed at a single center. HB mapping was performed using a commercially available multielectrode grid catheter in patients with complex CHD undergoing ventricular repair between 2019 and 2022 compared with an unmapped cohort. The primary outcome was postoperative AVB/PM.
Results:
A total of 149 patients with a median age of 1.9 years underwent HB mapping compared to 201 unmapped controls. Heterotaxy syndrome was present in 31%, ventricular septal defect in 95%, and prior single ventricle palliation in 68%. The HB was identified in 97% of cases. The median mapping time was 6 minutes. No episodes of intraoperative systemic air embolism occurred. In the entire cohort, the primary efficacy outcome of AVB/PM occurred in 9% of mapped patients as compared with 13% of unmapped patients (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.35-1.39; p = 0.31 on univariate analysis). For patients with heterotaxy syndrome, postoperative AVB/PM frequency was significantly reduced in mapped patients (2% [n = 1 of 46] vs. 16% [n = 11 of 67]; p = 0.026). Similarly, AVB/PM was reduced in mapped patients without L-malposed great arteries (n = 3 of 88) vs. 11% [n = 15 of 134]; p = 0.045).
Conclusions:
The authors conclude that intraoperative HB mapping can be performed safely and is associated with significantly reduced AVB/PM in select populations undergoing complex biventricular repair, including those with heterotaxy and non-L-malposed great arteries.
Perspective:
Early knowledge of the location of the conduction tissue in patients with complex congenital heart disease was based on the pioneering use of intraoperative mapping by MacDonald Dick at Boston Children’s Hospital in the 1970s. The current study reports results using modern equipment and techniques with the hopes of reducing postoperative heart block in patients undergoing complex biventricular repairs. The technique was beneficial in patients with heterotaxy as well as those without L-malposed great arteries. The lack of benefit for patients with L-looped ventricles may be related to the risk of heart block inherent to these lesions and difficulty in reducing and avoiding this complication.
Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Implantable Devices, EP Basic Science, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias
Keywords: Atrioventricular Block, Heart Defects, Congenital, Pacemaker, Artificial
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