Risk factors for atrial arrhythmia recurrence after atrial arrhythmia surgery with pulmonary valve replacement

Objectives

Atrial arrhythmias are a significant cause of late morbidity and mortality in patients after tetralogy of Fallot repair. However, reports on their recurrence following atrial arrhythmia surgery are limited. We aimed to identify the risk factors for atrial arrhythmia recurrence after pulmonary valve replacement (PVR) and arrhythmia surgery.

Methods

We reviewed 74 patients with repaired tetralogy of Fallot who underwent PVR for pulmonary insufficiency at our hospital between 2003 and 2021. Twenty-two patients (mean age, 39 years) underwent PVR and atrial arrhythmia surgery. A modified Cox-maze III was performed in 6 patients with chronic atrial fibrillation, and a right-sided maze was performed in 12 with paroxysmal atrial fibrillation, 3 with atrial flutter, and 1 with atrial tachycardia. Atrial arrhythmia recurrence was defined as any documented sustained atrial tachyarrhythmia requiring intervention. The influence of preoperative parameters on recurrence was assessed with the Cox proportional-hazards model.

Results

The median follow-up period was 9.2 years (interquartile range, 4.5-12.4). Cardiac death and redo-PVR due to prosthetic valve dysfunction were not observed. Eleven patients had atrial arrhythmia recurrence after discharge. Atrial arrhythmia recurrence-free rates were 68% at 5 years and 51% at 10 years after PVR and arrhythmia surgery. Multivariable analysis revealed that right atrial volume index (hazard ratio, 1.04; 95% confidence interval, 1.01-1.08, P = .009) was a significant risk factor for atrial arrhythmia recurrence after arrhythmia surgery and PVR.

Conclusions

Preoperative right atrial volume index was associated with atrial arrhythmia recurrence, which may assist in planning the timing of atrial arrhythmia surgery and PVR.

Improved Outcomes After Pulmonary Valve Replacement in Repaired Tetralogy of Fallot

BACKGROUND

The impact of pulmonary valve replacement (PVR) on major adverse clinical outcomes in patients with repaired tetralogy of Fallot (rTOF) is unknown.

OBJECTIVES

The purpose of this study was to determine whether PVR is associated with improved survival and freedom from sustained ventricular tachycardia (VT) in rTOF.

METHODS

A PVR propensity score was created to adjust for baseline differences between PVR and non-PVR patients enrolled in INDICATOR (International Multicenter TOF Registry). The primary outcome was time to the earliest occurrence of death or sustained VT. PVR and non-PVR patients were matched 1:1 on PVR propensity score (matched cohort) and in the full cohort, modeling was performed with propensity score as a covariate adjustment.

RESULTS

Among 1,143 patients with rTOF (age 27 ± 14 years, 47% PVR, follow-up 8.3 ± 5.2 years), the primary outcome occurred in 82. The adjusted HR for the primary outcome for PVR vs no-PVR (matched cohort n = 524) was 0.41 (95% CI: 0.21-0.81; multivariable model P = 0.010). Full cohort analysis revealed similar results. Subgroup analysis suggested beneficial effects in patients with advanced right ventricular (RV) dilatation (interaction P = 0.046; full cohort). In patients with RV end-systolic volume index >80 mL/m2, PVR was associated with a lower primary outcome risk (HR: 0.32; 95% CI: 0.16-0.62; P < 0.001). There was no association between PVR and the primary outcome in patients with RV end-systolic volume index ≤80 mL/m2 (HR: 0.86; 95% CI: 0.38-1.92; P = 0.70).

CONCLUSIONS

Compared with rTOF patients who did not receive PVR, propensity score-matched individuals receiving PVR had lower risk of a composite endpoint of death or sustained VT.

Decreased Muscle Strength in Children With Repaired Tetralogy of Fallot: Relation With Exercise Capacity

Background The aim of this study is to describe muscle strength in pediatric patients with repaired tetralogy of Fallot compared with healthy peers and to analyze the correlation between muscle strength and peak oxygen uptake, exercise capacity (mL/min). Methods and Results A prospective, cross-sectional study was carried out in the University Medical Center Groningen between March 2016 and December 2019, which included 8 -to-19-year-old patients with repaired tetralogy of Fallot. Exclusion criteria comprised the following: Down syndrome, unstable pulmonary disease and severe scoliosis affecting pulmonary function, neuromuscular disease, and mental or physical limitations that prohibit the execution of the functional tests. Muscle strength was compared with 2 healthy pediatric cohorts from the Northern Netherlands. Handgrip strength, maximal voluntary isometric contraction, and dynamic muscle strength in correlation with peak oxygen uptake, exercise capacity (mL/min) were the main outcomes of the study. The 67 patients with repaired tetralogy of Fallot (42% female; aged 12.9 [interquartile range, 10.0-16.3] years old) were compared with healthy children. The patients showed reduced grip strength (z-score [mean±SD] -1.5±1.2, P<0.001), and total muscle strength (z-score -0.9±1.3, P<0.001). Dynamic strength (Bruininks-Oseretsky test) was significantly reduced (z-score -0.3±0.8, P=0.001), but running, speed, and agility were normal (z-score 0.1±0.7, P=0.4). Univariate correlation analyses showed strong correlations between absolute peak oxygen uptake, exercise capacity (mL/min), and muscle strength (grip strength r=0.83, total muscle strength r=0.88; P<0.001). In multivariate analyses, including correction for age and sex, total muscle strength (B 0.3; P=0.009), and forced vital capacity (B 0.5; P=0.02) correlated with peak oxygen uptake, exercise capacity (mL/min), independent of conventional cardiovascular parameters. Conclusions Children with repaired tetralogy of Fallot show reduced muscle strength, which strongly correlated with their exercise performance.

Patient-Reported Outcomes After Tetralogy of Fallot Repair

BACKGROUND

Comprehensive assessment of tetralogy of Fallot (TOF) outcomes extends beyond morbidity and mortality to incorporate patient-reported outcomes (PROs), including quality of life (QOL) and health status (HS).

OBJECTIVES

This study explored PROs in adolescents and adults with TOF and delineated variables associated with PROs.

METHODS

This was a cross-sectional observational study within a larger prospective registry of adolescents and adults with repaired TOF and moderate or greater pulmonary regurgitation from North America, Europe, and Asia. Participants completed PROs, including a QOL linear analogue scale (QOL-LAS) and an HS visual analogue scale (HS-VAS). Scores were classified according to age cohorts: <18, 18 to 25, 26 to 40, and >40 years.

RESULTS

The study included 607 patients (46.3% female; median age 28.5 years). Median QOL-LAS scores (0-100) were similar across age cohorts (85, 80, 80, 80; P = 0.056). Median HS-VAS scores (0-100) were lowest for the oldest cohort (77) compared with the 3 younger cohorts (85, 80, 80) (P = 0.004). With advancing age, there were increased reports of poor mobility (P < 0.001) and pain or discomfort (P = 0.004); problems in these dimensions were reported by 19.1% and 37.2% of patients aged >40 years, respectively. Of factors associated with superior PROs on multivariable regression modeling (ie, being White, being nonsyndromic, having employment, and having better left ventricular function; P < 0.05), asymptomatic status (functional class I) was the variable associated with the greatest number of QOL and HS measures (P < 0.001).

CONCLUSIONS

Strategies to improve TOF outcomes should consider PROs alongside conventional clinical variables. Factors associated with poorer PROs represent opportunities to intervene to improve the lives of patients with TOF.

Systematic Electrophysiological Study Prior to Pulmonary Valve Replacement in Tetralogy of Fallot: A Prospective Multicenter Study

BACKGROUND

Ventricular arrhythmias and sudden death are recognized complications in tetralogy of Fallot. Electrophysiological studies (EPS) before pulmonary valve replacement (PVR), the most common reintervention in tetralogy of Fallot, could potentially inform therapy to improve arrhythmic outcomes.

METHODS

A prospective multicenter study was conducted to systematically assess EPS with programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR from January 2020 to December 2021. A standardized stimulation protocol was used across all centers.

RESULTS

A total of 120 patients were enrolled, mean age 39.2±14.5 years, 53.3% males. Sustained ventricular tachycardia was induced in 27 (22.5%) patients. When identifiable, the critical isthmus most commonly implicated (ie, in 90.0%) was between the ventricular septal defect patch and pulmonary annulus. Factors independently associated with inducible ventricular tachycardia were history of atrial arrhythmia (OR, 8.56 [95% CI, 2.43-34.73]) and pulmonary annulus diameter >26 mm (OR, 5.05 [95% CI, 1.47-21.69]). The EPS led to a substantial change in management in 23 (19.2%) cases: 18 (15.0%) had catheter ablation, 3 (2.5%) surgical cryoablation during PVR, and 9 (7.5%) defibrillator implantation. Repeat EPS 5.1 (4.8-6.2) months after PVR was negative in 8 of 9 (88.9%) patients. No patient experienced a sustained ventricular arrhythmia during 13 (6.1-20.1) months of follow-up.

CONCLUSIONS

Systematically performing programmed ventricular stimulation in patients with tetralogy of Fallot referred for PVR yields a high rate of inducible ventricular tachycardia and carries the potential to alter management. It remains to be determined whether a standardized treatment approach based on the results of EPS will translate into improved outcomes.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT04205461.

A newborn with ectrodactyly, tetralogy of Fallot, esophageal atresia, hypospadias and TP63 gene mutation: A new type of EEC Syndrome?

EEC syndrome is an autosomal dominant genetic disease with incomplete penetrance characterized by ectrodactyly, ectodermal dysplasia, and cleft lip/palate; these manifestations can differently occur in the affected subjects and can also be associated with other anomalies, such as in the urogenital tract.We reported the case of a newborn with prenatal diagnosis of EEC type 3 associated with severe cardiac abnormalities (Tetralogy of Fallot), high esophageal atresia with fistula and penoscrotal hypospadias.

Major Aortopulmonary Collaterals From Coronary Arteries and Dual Left Anterior Descending Artery in an Adult With Tetralogy of Fallot

Major aortopulmonary collaterals (APCs) are more common with tetralogy of Fallot (TOF) with pulmonary atresia. Collateral arteries, when present, arise most commonly from the descending thoracic aorta, less commonly from the subclavian arteries, and rarely from the abdominal aorta or its branches or from the coronary arteries. Collaterals arising from the coronary arteries can cause myocardial ischemia due to coronary steal phenomenon. They can be addressed either by endovascular interventions like coiling or surgical ligation during the intracardiac repair. Coronary anomalies are seen in 5%-7% of TOF patients. In approximately 4% of TOF patients, the left anterior descending artery (LAD) or an accessory LAD takes origin from the right coronary artery or right coronary sinus and crosses the right ventricular outflow tract in its course toward the left ventricle. Presence of such anomalous coronary anatomy poses certain challenges during intracardiac repair of TOF.

Ventricular function and biomarkers in relation to repair and pulmonary valve replacement for tetralogy of Fallot

OBJECTIVE

Cardiac surgery may cause temporarily impaired ventricular performance and myocardial injury. We aim to characterise the response to perioperative injury for patients undergoing repair or pulmonary valve replacement (PVR) for tetralogy of Fallot (ToF).

METHODS

We enrolled children undergoing ToF repair or PVR from four tertiary centres in a prospective observational study. Assessment-including blood sampling and speckle tracking echocardiography-occurred before surgery (T1), at the first follow-up (T2) and 1 year after the procedures (T3). Ninety-two serum biomarkers were expressed as principal components to reduce multiple statistical testing. RNA Sequencing was performed on right ventricular (RV) outflow tract samples.

RESULTS

We included 45 patients with ToF repair aged 4.3 (3.4 - 6.5) months and 16 patients with PVR aged 10.4 (7.8 - 12.7) years. Ventricular function following ToF repair showed a fall-and-rise pattern for left ventricular global longitudinal strain (GLS) (-18±4 to -13±4 to -20±2, p < 0.001 for each comparison) and RV GLS (-19±5 to -14±4 to 20±4, p < 0.002 for each comparison). This pattern was not seen for patients undergoing PVR. Serum biomarkers were expressed as three principal components. These phenotypes are related to: (1) surgery type, (2) uncorrected ToF and (3) early postoperative status. Principal component 3 scores were increased at T2. This increase was higher for ToF repair than PVR. The transcriptomes of RV outflow tract tissue are related to patients' sex, rather than ToF-related phenotypes in a subset of the study population.

CONCLUSIONS

The response to perioperative injury following ToF repair and PVR is characterised by specific functional and immunological responses. However, we did not identify factors relating to (dis)advantageous recovery from perioperative injury.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register: NL5129.

Bovine jugular vein conduit replacement after homograft degeneration in patients with tetralogy of Fallot: The results of re-redo cases

Background

This study aims to present our experience and results in terms of reconstruction with bovine jugular vein conduit in re-redo patients who developed severe homograft degeneration with pulmonary homograft valve replacement.

Methods

Between May 2018 and May 2021, a total of 10 re-redo patients (4 males, 6 females; mean age: 16.5±3.0 years; range, 12 to 21 years) who underwent bovine jugular vein conduit replacement due to homograft degeneration were retrospectively analyzed. The clinical, pre-, intra-, and postoperative data of the patients were recorded.

Results

The mean age of the second operation (homograft replacement) was 8.5±3.8 (range, 4 to 14) years in the patients who underwent homograft replacement. No postoperative mortality was observed. When the pre- and postoperative findings were compared, the right ventricular outflow tract gradient, the degree of pulmonary and tricuspid regurgitation, and right ventricular dilatation were regressed (p<0.05). A significant improvement in the New York Heart Association functional class was observed in all patients after surgery.

Conclusion

After tetralogy of Fallot corrective surgery, repetitive surgical interventions are inevitable due to pulmonary valve deterioration. Therefore, a bovine jugular vein conduit may be a good alternative for conduit preference after pulmonary homograft failure in re-redo cases.

Correlation of venous to arterial carbon dioxide partial pressure difference with other cardiac output indices in patients undergoing intracardiac repair for tetralogy of fallot

Background

Clearance of tissue carbon dioxide by circulation is measured by venous to arterial carbon dioxide partial pressure difference (AVCO2) and is correlated with cardiac output (CO) in critically ill adult patients. This study aimed to correlate AVCO2 with other CO indices like arteriovenous oxygen saturation difference (AVO2), central venous oxygen saturation (ScVO2), and serum lactate in pediatric patients undergoing intracardiac repair (ICR) for tetralogy of Fallot (TOF).

Methods

We conducted a prospective observational study in 50 patients, of age 5 months to 5 years, undergoing ICR for TOF and analyzed AVO2, AVCO2, ScVO2, and lactate from arterial and venous blood gas pairs obtained at different time intervals from admission to pediatric intensive care unit (PICU) (T0), at 6 h (T1), 12 h (T2), 24 h (T3), and 48 h (T4) postoperatively. Bivariate correlations were analyzed using Pearson for parametric variables.

Results

Admission AVCO2 was not correlated with AVO2 (R2 = 0.166, P = 0.246), ScVO2 (R2 = -2.2, P = 0.124), and lactate (R2 = -0.07, P = 0.624). At T1, AVCO2 was correlated with AVO2 (R2 = 0.283, P = 0.0464) but not with ScVO2 (R2 = - 0.25, P = 0.079) and lactate (R2 = -0.07, P = 0.623). At T2, T3 and T4, AVCO2 was correlated with AVO2 (R2 = 0.338,0.440 & 0.318, P = 0.0162, 0.0013, and 0.024), ScVO2 (R2 = - 0.344, - 0.488, and -0.366; P = 0.0143, <0.0001, and 0.017), and lactate (R2 = 0.305, 0.467 and 0.607; P = 0.0314, 0.00062 and <0.0001). AVCO2 was negatively correlated with ScVO2. No correlation observed between admission AVCO2 and mechanical ventilation duration. Two nonsurvivors had higher value of admission AVCO2 compared to survivors.

Conclusion

AVCO2 is correlated with other CO surrogates like AVO2, ScVO2, and lactate in pediatric patients undergoing ICR for TOF.

Impaired ascending aortic elasticity in fetuses with tetralogy of Fallot

OBJECTIVES

Aortic wall stiffness has been reported in infants with tetralogy of Fallot (ToF) and may contribute to long-term aortic dilation even after corrective repair surgery. However, little is known about aortic elasticity in fetuses with ToF and the association with neonatal aortic dilation. The objectives of this study were to assess measures of elasticity of the ascending aorta (AAo) in fetuses with ToF and explore the association with neonatal aortic annular dilation in this population.

METHODS

Seventy-six singleton fetuses with ToF and 76 control fetuses of singleton low-risk pregnancies were enroled into this prospective study. Fetal measures of AAo elasticity, including mean longitudinal strain (MLS), global circumferential strain (GCS) and fractional area change (FAC), were assessed by velocity vector imaging. The z-score of the aortic valve (AV) diameter at the level of the annulus, as a measure of aortic annular dilation, was determined in newborns. Logistic regression analysis was used to investigate the association between fetal measures of AAo elasticity and neonatal aortic annular dilation (defined as an AV annular z-score > 2) in cases with ToF identified prenatally.

RESULTS

Median MLS, GCS and FAC in fetuses with ToF were lower than those in normal fetuses (7.52% vs 12.15% for MLS, 22.05% vs 29.73% for GCS and 34.2% vs 48.3% for FAC, all P < 0.001). Aortic annular dilation was present in 53/76 (69.7%) newborns with ToF. After adjustment for gestational age at fetal echocardiography and birth weight, fetal MLS, GCS and FAC were independently associated with aortic annular dilation neonatally, with odds ratios of 0.66, 0.78 and 0.82, respectively (P < 0.05). The best cut-off values of these prenatal measures of AAo elasticity for predicting neonatal aortic annular dilation in fetuses with ToF were 9.02% for MLS, 23.56% for GCS and 37.2% for FAC (P < 0.001), with areas under the receiver-operating-characteristics curves of 0.94, 0.91 and 0.93, respectively.

CONCLUSION

Measures of AAo elasticity are decreased in fetuses with ToF. Impaired AAo elasticity in the fetal period is associated with aortic annular dilation postnatally. Additional research is needed to evaluate the relationship between the AAo elasticity injury pattern and degeneration of AAo elasticity under stress as well as the long-term outcome in this population. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Tricuspid Regurgitation in Patients with Tetralogy of Fallot

Tricuspid regurgitation in patients with repaired tetralogy of Fallot is an important finding with a wide spectrum of primary and secondary etiologies. Moderate or severe tricuspid regurgitation is associated with a greater incidence of atrial tachyarrhythmias in these patients. It remains uncertain which patients with repaired tetralogy of Fallot may benefit from a tricuspid valve intervention at the time of pulmonary valve replacement.

Contemporary pregnancy outcomes for women with moderate and severe congenital heart disease

Background

Women with congenital heart disease (CHD) are surviving into adulthood, with more undergoing pregnancy.

Methods

Retrospective review of the Vizient database from 2017-2019 for women 15-44 years old with moderate, severe or no CHD and vaginal delivery or caesarean section. Demographics, hospital outcomes and costs were compared.

Results

There were 2,469,117 admissions: 2,467,589 with no CHD, 1277 with moderate and 251 with severe CHD. Both CHD groups were younger than no CHD, there were fewer white race/ethnicity in the no CHD group and more women with Medicare in both CHD groups compared to no CHD. With increasing CHD severity there was an increase in length of stay, ICU admission rates and costs. There were also higher rates of complications, mortality and caesarean section in the CHD groups.

Conclusion

Pregnant women with CHD have more problematic pregnancies and understanding this impact is important to improve management and decrease healthcare utilization.

The Use of Automated Atrial CMR Measures and a Novel Atrioventricular Coupling Index for Predicting Risk in Repaired Tetralogy of Fallot

Atrial size and function have been recognized as markers of diastolic function, and diastolic dysfunction has been identified as a predictor of adverse outcomes in repaired tetralogy of Fallot (rTOF). This was a retrospective single-center study with the objective of investigating the use of atrial measurements obtained via CMR for predicting outcomes in rTOF patients. Automated contours of the left and right atria (LA and RA) were performed. A novel parameter, termed the Right Atrioventricular Coupling Index (RACI), was defined as the ratio of RA end-diastolic volume to right ventricle (RV) end-diastolic volume. Patients were risk-stratified using a previously validated Importance Factor Score for the prediction of life-threatening arrhythmias in rTOF. Patients with a high-risk Importance Factor Score (>2) had a significantly larger minimum RA volume (p = 0.04) and RACI (p = 0.03) compared to those with scores ≤2. ROC analysis demonstrated RACI to be the best overall predictor of a high-risk Importance Factor Score (AUC 0.73, p = 0.03). Older age at the time of repair and a diagnosis of pulmonary atresia were associated with a larger RACI. Automated atrial CMR measurements are easily obtained from standard CMRs and have the potential to serve as noninvasive predictors of adverse outcomes in rTOF.

Genetic Variants of ISL1 Gene Promoter Identified from Congenital Tetralogy of Fallot Patients Alter Cellular Function Forming Disease Basis

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease in newborns. ISL1 is a master transcription factor in second heart field development, whereas the roles of ISL1 gene promoter variants in TOF patients have not been genetically investigated. Total DNA extraction from 601 human subjects, including 308 TOF patients and 293 healthy controls, and Sanger sequencing were performed. Four variants (including one novel heterozygous variant) within the ISL1 gene promoter were only found in TOF patients. Functional analysis of DNA sequence variants was performed by using the dual-luciferase reporter assay and demonstrated that three of the four variants significantly decreased the transcriptional activity of ISL1 gene promoter in HL-1 cells (p < 0.05). Further, the online JASPAR database and electrophoretic mobility shift assay showed that the three variants affected the binding of transcription factors and altered ISL1 expression levels. In conclusion, the current study for the first time demonstrated that the variants identified from the ISL1 gene promoter region are likely involved in the development of TOF by affecting the transcriptional activity and altering the ISL1 expression level. Therefore, these findings may provide new insights into the molecular etiology and potential therapeutic strategy of TOF.

[Multimodality imaging of adult patients with surgically corrected tetralogy of Fallot. Results from the CSONGRAD Registry]

INTRODUCTION

There is an increasing ratio of surviving patients with congenital heart disease including tetralogy of Fallot.

OBJECTIVE

The aim of the present study was a comparative assessment of echocardiographic and cardiac magnetic resonance imaging-derived findings in patients with tetralogy of Fallot following early total reconstruction versus early palliation/late correction.

METHODS

The study comprised 17 patients with tetralogy of Fallot (mean age: 28.6 ± 10.4 years; 10 males). Early total reconstruction was performed in 10 cases (mean age: 25.0 ± 8.0 years; 8 males), while early palliation/late construction was done in 7 subjects (mean age: 33.7 ± 11.8 years; 2 males). Complete two-dimensional Doppler echocardiography and cardiac resonance imaging were performed in all patients.

RESULTS

During long-term follow-up, lower left ventricular end-systolic (40.50 ± 10.55 ml/m2 vs. 58.14 ± 19.07 ml/m2, p = 0.013) and end-diastolic volume indices (86.60 ± 12.62 ml/m2 vs. 116.70 ± 23.70 ml/m2, p = 0.002) and stroke volume index (46.00 ± 6.77 ml/m2 vs. 58.43 ± 7.11 ml/m2, p = 0.001) could be detected, which were associated with higher echocardiographic left ventricular ejection fraction (69.75 ± 6.80% vs. 61.67 ± 8.80%, p = 0.038) in patients with tetralogy of Fallot following early total reconstruction as compared to that of subjects late after early palliation/late correction. In regard with the right heart, larger right ventricular muscle mass (72.33 ± 21.03 g/m2 vs. 51.33 ± 22.33 g/m2, p = 0.044) could be seen in patients with tetralogy of Fallot following early total reconstruction.

CONCLUSION

Beneficial left ventricular morphological and functional parameters, but more pronounced right ventricular hypertrophy could be detected in patients with tetralogy of Fallot following early total reconstruction as compared to that of subjects late after early palliation/late correction. Orv Hetil. 2023; 164(5): 186-194.

Abnormalities of the Width of the Four-Chamber View and the Area, Length, and Width of the Ventricles to Identify Fetuses at High-Risk for D-Transposition of the Great Arteries and Tetralogy of Fallot

OBJECTIVES

The prenatal detection of D-Transposition of the great arteries (D-TGA) and tetralogy of Fallot (TOF) has been reported to be less than 50% to as high as 77% when adding the outflow tracts to the four-chamber screening protocol. Because many examiners still struggle with the outflow tract examination, this study evaluated whether changes in the size and shape of the heart in the 4CV as well as the ventricles occurred in fetuses with D-TGA and TOF could be used to screen for these malformations.

METHODS

Forty-four fetuses with the pre-and post-natal diagnosis of D-TGA and 44 with TOF were evaluated between 19 and 36 weeks of gestation in which the 4CV was imaged. Measurements of the end-diastolic width, length, area, and global sphericity index were measured for the four-chamber view and the right and left ventricles. Using z-score computed values, logistic regression was performed between the 88 study and 200 control fetuses using the hierarchical forward selection protocol.

RESULTS

Logistic regression identified 10 variables that correctly classified 83/88 of fetuses with TOF and TGA, for a sensitivity of 94%. Six of 200 normal controls were incorrectly classified for a false-positive rate of 3%. The area under the receiver operator classification curve was 98.1%. The true positive rate for D-TGA was 93.2%, with a false-negative rate to 6.8%. The true positive rate for TOF was 95.5%, with a false negative rate of 4.5%.

CONCLUSIONS

Measurements of the 4CV and of the RV and LV may help identify fetuses at risk for D-TGA or TOF.

End-diastolic forward flow in repaired tetralogy of Fallot: Mid-term outcomes from a single center

Background

Pulmonary arterial end-diastolic forward flow (EDFF) following repaired tetralogy of Fallot (rTOF) is recognized as right ventricular (RV) restrictive physiology, which is closely related to poor prognosis. This study sought to review mid-term experience and investigate the risk factors of EDFF in the rTOF patients.

Methods

From September 2016 to January 2019, 100 patients (age < 18 years old) who underwent complete tetralogy of Fallot (TOF) repair were enrolled and were divided into EDFF group (n = 52) and non-EDFF group (n = 48) based on the presence of postoperative EDFF. Elastic net analysis was performed for variable selection. Univariate and multivariate logistic analyses were used to analyze the correlation between risk factors and EDFF.

Results

End-diastolic forward flow group had lower systolic blood pressure (P = 0.037), diastolic blood pressure (P = 0.027), and higher vasoactive-inotrope score within 24 h after surgery (P = 0.022) than non-EDFF group. Transannular patch (TAP) was an independent predictor of postoperative EDFF [P = 0.029, OR: 2.585 (1.102∼6.061)]. Patients were followed up for a median of 2.6 years [interquartile range (IQR) 1.6] after the first TOF repair. During follow-up, the prevalence of the EDFF was lower in those with pulmonary valve (PV) reconstructions than that in those undergoing patch enlargement without PV reconstructions in the primary TOF repair (P < 0.001).

Conclusion

End-diastolic forward flow was associated with TAP. Patients with EDFF might have a transient hemodynamic instability in the early postoperative period. PV reconstructions in the TOF repair might reduce the incidence of EDFF in the mid-term follow-up.

Visibility of Pulmonary Valve and Pulmonary Regurgitation on Intracardiac Echocardiography in Adult Patients with Tetralogy of Fallot

Pulmonary regurgitation (PR) is a risk factor for sudden cardiac death in adult patients with repaired tetralogy of Fallot (TOF). However, transthoracic echocardiography (TTE) cannot fully visualize the pulmonary valve (PV) and PR. We investigated whether intracardiac echocardiography (ICE) could visualize the PV and PR better than TTE. Thirty adult patients with TOF (mean age 33 ± 15 years) scheduled for cardiac catheterization underwent ICE. The visualization of PV and the severity of PR were classified into three grades. ICE depicted the PV better than TTE (ICE vs. TTE: not visualized, partially visualized, and fully visualized: n = 1 [3%], n = 13 [43%], and n = 16 [53%] vs. n = 14 [47%], n = 13 [43%], and n = 3 [10%], p < 0.001). Especially in patients after pulmonary valve replacement (PVR), the PV was more fully visualized by ICE. The assessment of PR by TTE underestimated the severity of PR in comparison to cardiac magnetic resonance imaging (MRI) (severe PR: 8 [28%] vs. 22 [76%], p = 0.004), while there was no discrepancy between the results of ICE and MRI (21 [72%] vs. 22 [76%], p = 1.000). In comparison to TTE, ICE can safely provide better visualization of the PV and PR in adults with TOF, especially in patients who have undergone PVR.

Clinical Characteristics of Coronary-to-Pulmonary Artery Fistula in Patients with Pulmonary Atresia and Ventricular Septal Defect

The existence of a coronary-to-pulmonary artery fistula (CPF) in pulmonary atresia with ventricular septal defect (PAVSD) potentially affects treatment; however, its clinical features have not been comprehensively described due to the disease's rarity. We reviewed 69 cases from 42 studies to reveal the clinical overview of patients with CPF and PAVSD. Among the included patients, the male-to-female ratio was exactly 1:1, and only two patients (3%) exhibited the 22q11.2 microdeletion syndrome. Regarding anatomical features, CPFs originated from the left coronary artery in 65% of patients, and 62% had other major aortopulmonary collateral arteries. Thirty-nine percent of patients had a definitive CPF diagnosis at 0 years of age, whereas 10% were diagnosed in adulthood. Seventy percent underwent catheter angiography to obtain a definitive CPF diagnosis. Ninety-five percent of patients underwent cardiac surgery, and among them, 43% underwent palliative surgery, whereas 52% underwent one-stage repair. Four patients including three adult patients developed cardiac dysfunction due to myocardial ischemia, and three of them exhibited improved cardiac function after the intervention for CPF. Of all the patients, 88% survived and 12% died. The surgical strategy and prognosis were similar to those in PAVSD patients without CPF. This review provides detailed clinical phenotypes that are potentially useful in enhancing the management of patients with this rare disease.

Tetralogy of Fallot Presenting with Superior Vena Cava Syndrome - A Rare Presentation

Tetralogy of Fallot (TOF) presenting with superior vena cava (SVC) syndrome is an exceedingly rare scenario. The diagnosis of this condition is still a difficult task due to its unspecific clinical features and unclear recommendations for the best diagnostic tools. We report an interesting case of a 23-year-old male who was found to have TOF with the presentation of SVC syndrome after a sequential diagnosis. The timely diagnosis helped in the successful management of the patient. Through this case, we want to make clinicians aware of such a rare association and its diagnosis.

ALDH1A2-related disorder: A new genetic syndrome due to alteration of the retinoic acid pathway

Aldehyde Dehydrogenase 1, Family Member A2 (ALDH1A2) is essential for the synthesis of retinoic acid from vitamin A. Studies in model organisms demonstrate a critical role for ALDH1A2 in embryonic development, yet few pathogenic variants are linked to congenital anomalies in humans. We present three siblings with multiple congenital anomaly syndrome linked to biallelic sequence variants in ALDH1A2. The major congenital malformations affecting these children include tetralogy of Fallot, absent thymus, diaphragmatic eventration, and talipes equinovarus. Upper airway anomalies, hypocalcemia, and dysmorphic features are newly reported in this manuscript. In vitro functional validation of variants indicated that substitutions reduced the expression of the enzyme. Our clinical and functional data adds to a recent report of biallelic ALDH1A2 pathogenic variants in two families with a similar constellation of congenital malformations. These findings provide further evidence for an autosomal recessive ALDH1A2-deficient recognizable malformation syndrome involving the diaphragm, cardiac and musculoskeletal systems.

Tetralogy of Fallot with aortic stenosis and common arterial trunk: Is there a morphological overlap?

Tetralogy of Fallot with aortic stenosis is an extremely rare entity which bears some morphological similarities with the common arterial trunk. Through two illustrative cases of TOF with aortic stenosis we describe the shared anatomical peculiarities of the two anomalies with a review of the possible genetic and developmental factors responsible for the association.