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Using preoperative cardiac computed tomographic conduction axis prediction to avoid damage in congenital left

Justin T Tretter1, Lama Dakik1, Iqbal El-Assaad1

  • 1Department of Pediatric Cardiology, Congenital Valve Procedural Planning Program, Cleveland Clinic Children's, and Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.

The Journal of Thoracic and Cardiovascular Surgery
|March 4, 2026
PubMed

Insights

Pre-surgical cardiac CT accurately estimates the conduction axis, significantly reducing high-grade atrioventricular block after congenital heart surgery. This imaging technique aids surgeons in avoiding conduction damage during complex aortic valve and left ventricular outflow tract procedures.

Area of Science:

  • Cardiovascular Surgery
  • Medical Imaging
  • Cardiac Electrophysiology

Background:

  • High-grade atrioventricular block is a common complication following congenital aortic valve, root, and left ventricular outflow tract (LVOT) surgery.
  • Accurate pre-operative assessment of the conduction system is crucial for mitigating this risk.

Purpose of the Study:

  • To evaluate the utility of pre-surgical cardiac computed tomography (CT) in estimating the conduction axis.
  • To assess the potential of this method in reducing post-operative atrioventricular block in patients undergoing congenital heart surgery.

Main Methods:

  • Patients with congenital aortic valve, root, or LVOT disease undergoing surgery from February 2022 to August 2025 were included.
  • Pre-surgical CT was used to estimate the anatomical location of the atrioventricular node, His bundle, and left bundle branch.
  • These landmarks were identified relative to the aortic virtual basal ring plane to guide surgical avoidance.

Main Results:

  • Fifty-three patients (mean age 32 years) were analyzed, with common diagnoses including bileaflet aortic valves and LVOT obstruction.
  • The study identified specific mean depths for the atrioventricular node, His bundle, and left bundle branch relative to the aortic virtual basal ring.
  • The incidence of high-grade atrioventricular block requiring permanent pacemaker was 1.9%, a significant reduction compared to a historical cohort (10%).

Conclusions:

  • CT-based estimation of the conduction axis appears to mitigate the risk of conduction damage during congenital LVOT, aortic valve, and root surgery.
  • Further multi-center, multi-surgeon prospective studies are needed to validate this promising approach.
Abstract

Keywords:
aortic valve surgerycardiac computed tomographycomplete heart blockconduction systempermanent pacemaker insertion

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