Right Ventricular Systolic Function After the Cone Procedure for Ebstein's Anomaly: Comparison Between Echocardiography and Cardiac Magnetic Resonance

Association Between Right Ventricular Systolic Parameters Measured by Echocardiography and Stroke Volume Derived From Pulmonary Artery Catheter in Ischemic Cardiogenic Shock

OBJECTIVE

To determine the right ventricular (RV) systolic function echocardiographic parameter best associated with native stroke volume (SV) by thermodilution via a pulmonary artery catheter (PAC) in patients admitted to intensive care with ST elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).

DESIGN, SETTING, AND PARTICIPANTS

An observational cohort study of 43 prospectively identified patients admitted to a tertiary cardiac intensive care unit in London, United Kingdom.

INTERVENTIONS

Simultaneous collection of comprehensive transthoracic echocardiographic, clinical, and PAC-derived hemodynamic data. Seven RV systolic function parameters were correlated with the PAC-derived SV.

MEASUREMENTS AND MAIN RESULTS

The median patient age was 61 years (interquartile range [IQR], 52-67 years), and 36 of the 43 patients (84%) were male. The median PAC-derived SV and left ventricular ejection fraction were 57 mL (IQR, 39-70 mL) and 31% (IQR, 22%-35%), respectively. The RV outflow tract velocity time integral (RVOT VTI) and tricuspid plane systolic excursion (TAPSE) correlated significantly with the PAC-derived SV (r = 0.42 [p = 0.007] and r = 0.37 [p = 0.02], respectively). The RVOT VTI was independently associated with and predicted low PAC-derived SV (odds ratio, 1.3; p = 0.03) with a good area under the curve (AUC = 0.71; p = 0.02). An RVOT VTI <12.7 cm predicted low PAC-derived SV with a sensitivity of 66% and specificity of 72%.

CONCLUSIONS

RVOT VTI is the echocardiographic RV systolic function parameter that best correlates with PAC-derived native SV in patients with STEMI complicated by CS. This parameter can help guide the hemodynamic management of this cohort.

Large Right Atrial Size on Cardiac MRI is Associated with Post-operative Right Ventricular Dysfunction After the Cone Operation for Ebstein Anomaly

The cone operation has revolutionized care for patients with Ebstein anomaly; however, acute post-operative right ventricular dysfunction (RVD) is common in this patient population. A single-center, retrospective review of 28 patients with Ebstein anomaly who underwent cardiac MRI (CMR) prior to cone reconstruction of the tricuspid valve was conducted. Measurements of atrial and ventricular size/function were assessed. Post-operative RVD was defined as the presence of moderate or severe systolic dysfunction on discharge echo. A two-tail t test was employed to compare the two groups. The average age at operation was 21.4 years (range 1.6-57.8) and 14 (50%) had RVD at discharge. Patients with post-operative RVD had significantly larger pre-operative right atrial (RA) maximum volume (p = 0.016) and RA minimum volume (p = 0.030). Patients with RVD had smaller pre-operative left atrial (LA) minimum volume (p = 0.012). Larger pre-operative right ventricular (RV) end-systolic volume (p = 0.046), lower RV ejection fraction (0.029), and smaller left ventricular (LV) end-diastolic volume (p = 0.049) were significantly associated with post-operative RVD. Post-operative RVD was associated with longer milrinone duration (p = 0.009) and higher maximum milrinone dose (p = 0.005) but was not associated with intensive care or hospital length of stay (p = 0.19 and 0.67, respectively). Increased RA and RV dilation and decreased LA and LV volumes are associated with the development of post-operative RVD following cone operation for Ebstein anomaly. Post-operative RVD affects milrinone dose and duration but is not associated with increased length of stay.

Temporal change in cardiac function and clinical indices in adults with valvular pulmonic stenosis

Background

Patients with palliated pulmonary valve stenosis (PVS) have less cardiac remodeling and symptoms as compared to patients with repaired tetralogy of Fallot (TOF) presenting with similar severity of right ventricular outflow tract (RVOT) disease. What is not known is whether patients with PVS versus TOF presenting with similar severity of RVOT disease at baseline, would have similar (or different) pace of cardiac remodeling and disease progression over time. The study objective was to compare temporal changes in clinical and cardiac function indices between adults with palliated PVS and repaired TOF presenting with moderate/severe RVOT disease.

Methods

Cardiac function indices (based on strain imaging) and clinical indices (N-terminal pro-B-type natriuretic peptide [NT-proBNP], model for end-stage liver disease excluding international normalized ratio [MELD-XI], peak oxygen consumption [VO2]), were assessed at baseline, 3 years, and 5 years. Temporal changes were calculated as relative changes from baseline (Δ). Cardiovascular adverse event was assessed as time-to-event outcome.

Results

Compared to TOF group (n = 173), the PVS group (n = 173) had less temporal change in right atrial reservoir strain (-9±4% versus -21 ± 6%, p < 0.001), RV free wall strain (-8±4% versus -20 ± 5%, p < 0.001), NT-proBNP (8 ± 5% versus 17 ± 6 %, p < 0.001), MELD-XI (6 ± 4% versus 19 ± 4%, p = 0.008), and peak VO2 (-7±3% versus -12 ± 7%, p < 0.001) at 5 years. The 5-year freedom from cardiovascular adverse event was higher in the PVS group (76% versus 54%, p = 0.01).

Conclusions

These data suggest that a less frequent clinical and imaging follow-up may be appropriate in patients with PVS (as compared to patients with TOF).

Intraoperative Transesophageal Echocardiography Evaluation of Tricuspid Valve Re-repair for Ebstein's Anomaly

Postoperative stenosis or regurgitation of the tricuspid valve is common and affects the prognosis after repair surgery of Ebstein's anomaly. However, it is unclear how intraoperative echocardiography influences the postoperative course. We report a longitudinal echocardiography course including intraoperative transesophageal echocardiography in a cone reconstruction procedure for Ebstein's anomaly in a 17-year-old woman. Tight tricuspid valvuloplasty was preferred, but the tricuspid annulus enlarged rather after surgery. The evaluation of the tricuspid valve form and function using intraoperative echocardiography could support the surgeon's impression.

Prognostic Performance of Right Ventricular Global Longitudinal Strain Measurements in Patients With Ebstein Anomaly

BACKGROUND

There are limited data on the prognostic role of right ventricular global longitudinal strain (RVGLS) in patients with Ebstein anomaly.

OBJECTIVES

This study sought to assess the relationship between RVGLS and mortality and to compare prognostic performance of RVGLS with conventional echocardiographic indices of right ventricular (RV) systolic function.

METHODS

This study identified adults with Ebstein anomaly with echocardiographic assessment of RV systolic function (RVGLS, RV fractional area change [RVFAC], RV tissue Doppler systolic velocity [RV s'], and tricuspid annular plane systolic excursion [TAPSE]) from 2003 to 2020. For ease of presentation, RVGLS was modeled as absolute values (ie, without the negative sign).

RESULTS

Of 620 patients (median age 37 years; men 261 [42%]), the mean absolute RVGLS, RVFAC, RV s', and TAPSE were 18% ± 5%, 32% ± 9%, 14 ± 6 cm/s, and 22 ± 8 mm, respectively. There were correlations between absolute RVGLS and RVFAC (r = 0.71; P < 0.001), between absolute RVGLS and RV s' (r = 0.41; P = 0.03), and between absolute RVGLS and TAPSE (r = 0.44; P = 0.002). Of 620 patients, 47 (8%) died during follow-up, and 34 of these deaths were cardiovascular. Absolute RVGLS was independently associated with all-cause mortality (adjusted HR: 0.94; 95% CI: 0.92-0.96 per unit increase) and cardiovascular mortality (adjusted HR: 0.92; 95% CI: 0.90-0.94 per unit increase). Absolute RVGLS had superior prognostic power (ie, ability to predict mortality) as compared with RVFAC, RV s', or TAPSE.

CONCLUSIONS

These data support the use of RVGLS for risk stratification in Ebstein anomaly, and further studies are required to assess how interventions may affect different patients according to risk stratification.

Comparison between pre- and post-contrast cardiac MRI cine images: the impact on ventricular volume and strain measurement

To explore whether contrast agent administration will affect ventricular volume and strain parameters measured on cardiac magnetic resonance cine images. This prospective study enrolled 88 patients, including 32 patients with cardiac amyloidosis (CA), 32 patients with hypertrophic cardiomyopathy (HCM), and 24 control participants, to perform steady-state free precession (SSFP)-cine imaging twice, respectively before and after contrast agent injection. Indexed left and right ventricular (LV and RV) volume and LV strain parameters (peak radial strain [PRS], peak circumferential strain [PCS], peak longitudinal strain [PLS]) were analyzed and compared between the pre- and post-contrast cine groups. Compared to the group of pre-contrast cine, the end-diastolic volume index (EDVi) and end-systolic volume index (ESVi) significantly increased in the group using post-contrast cine images (all p < 0.05), especially in the right ventricle. After contrast injection, the right ventricular ejection fraction (RVEF) decreased significantly (p < 0.05), while the left ventricular ejection fraction (LVEF) only reduced for patients with HCM (p < 0.05). The PRS (37.1 ± 15.2 vs. 32.0 ± 15.4, p < 0.001) and PCS (- 14.9 ± 4.3 vs. - 14.0 ± 4.1, p < 0.001) derived from post-contrast cine images reduced significantly in all patients and this tendency remained in subgroup analysis except for PCS in the control group. The administration of a contrast agent may influence the measurements of ventricular volume and strain. Acquiring pre-contrast cine images were suggested for patients who required more accurate right ventricle evaluation or precise strain assessment.

Multimodality Imaging in Ebstein Anomaly

Ebstein anomaly is the most common form of tricuspid valve congenital anomalies. The tricuspid valve is abnormal with different degrees of displacement of the septal leaflet and abnormal rotation of the valve towards the right ventricular outflow tract. In severe forms, it results in significant tricuspid regurgitation and requires surgical repair. There is an increased interest in understanding the anatomy of the tricuspid valve in this lesion as the surgical repair has evolved with the invention and wide adoption of the cone operation. Multimodality imaging plays an important role in diagnosis, follow-up, surgical planning and post-operative care. This review provides anatomical tips for the cardiac imagers caring for patients with Ebstein anomaly and will help provide image-based personalized medicine.

Evaluation of right ventricle systolic function after tetralogy of Fallot repair: A systematic review comparing cardiac magnetic resonance and global longitudinal strain

BACKGROUND

Most patients who undergo tetralogy of Fallot (TOF) repair experience late right ventricle (RV) dysfunction due to pulmonary valve regurgitation (PVR). Cardiac magnetic resonance (CMR) is the gold standard method for evaluating RV during follow-up. Global longitudinal strain (GLS) has been introduced as a novel method for the assessment of RV dysfunction. We aimed to compare the feasibility of GLS and CMR for assessing RV function after TOF repair.

METHODS

We systematically reviewed the English literature using PubMed, SciELO and Google Scholar for articles published between January 1, 2015, and December 31, 2020. Articles evaluating RV function comparing by GLS and CMR after TOF repair were included.

RESULTS

Nine studies including 465 patients were analyzed. Most patients were men (280; 60%), the male:female ratio was 1.5:1, and the age range was .8 to 57.7 years. The mean follow-up time was 6 to 32 months. The correlation between RV GLS and RV ejection fraction (EF) by CMR was negative for the articles and varied from moderate to strong (r = -.45, r = -.60, r = -.76).

CONCLUSION

Right ventricle GLS can be considered for routine follow-up of TOF repair patients, even though CMR remains the noninvasive gold standard method. Using a single parameter may not allow comparison of the accuracy of 3D RV EF by using CMR and GLS. Further studies with a larger number of patients undergoing TOF repair are required to evaluate the correlation between these examinations.

Ebstein's Anomaly: From Fetus to Adult-Literature Review and Pathway for Patient Care

Ebstein's anomaly, first described in 1866 by Dr William Ebstein, accounts for 0.3-0.5% of congenital heart defects and represents 40% of congenital tricuspid valve abnormalities. Ebstein's anomaly affects the development of the tricuspid valve with widely varying morphology and, therefore, clinical presentation. Associated congenital cardiac lesions tend to be found more often in younger patients and may even be the reason for presentation. Presentation can vary from the most extreme form in fetal life, to asymptomatic diagnosis late in adult life. The most symptomatic patients need intensive care support in the neonatal period. This article summarizes and analyzes the literature on Ebstein's anomaly and provides a framework for the investigation, management, and follow-up of these patients, whether they present via fetal detection or late in adult life. For each age group, the clinical presentation, required diagnostic investigations, natural history, and management are described. The surgical options available for patients with Ebstein's anomaly are detailed and analyzed, starting from the initial mono-leaflet repairs to the most recent cone repair and its modifications. The review also assesses the effects of pregnancy on the Ebstein's circulation, and vice versa, the effects of Ebstein's on pregnancy outcomes. Finally, two attached appendices are provided for a structured echocardiogram protocol and key information useful for comprehensive Multi-Disciplinary Team discussion.

Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach

As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.

Cardiac MRI predictors of right ventricular dysfunction after the Da Silva cone operation for Ebstein's anomaly

Introduction

Despite the clinical benefits of the cone operation for Ebstein's anomaly, significant right ventricular (RV) dysfunction is frequently seen immediately after the procedure and if persistent may portend worse long-term outcomes. In this study we sought to evaluate the predictors of RV dysfunction after the cone operation using preoperative CMR.

Methods

This was a retrospective review of 26 consecutive patients who had the cone operation. Patients with significant RV dysfunction (RVD), defined as moderate or severe dysfunction by discharge echocardiogram, were compared to patients with no or mild dysfunction (no RVD).

Results

The median age at the operation was 12.2 years (interquartile range (IQR): 4.9-31.7 years). Eighteen patients (69%) had RVD. Patients with RVD had worse preoperative RV ejection fraction (36 ​± ​15 vs 49 ​± ​11%, p ​= ​0.02) and a larger cardiothoracic (CT) index (44 ​± ​8 vs 37 ​± ​6, p ​= ​0.03). The tricuspid valve was more severely abnormal in the RVD group with higher rotational angle (45 ​± ​17 vs 23 ​± ​10°, 0.03) and higher displacement index (39 ​± ​18 vs 23 ​± ​12%, p ​= ​0.02). RVD associated with a higher vasoactive inotropic score (P ​< ​0.01) and a trend towards a longer intensive care stay (p ​= ​0.07).

Conclusion

RVD is common after the cone operation and associated with higher need for postoperative inotropes. Predictors include lower preoperative RV ejection fraction, a more dilated heart and more severe tricuspid valve abnormality. Preoperative CMR is an important tool in preoperative assessment and helps predict RVD.

Impact of Cone vs. Hetzer Repair on Postoperative Outcomes in Patients With Ebstein's Anomaly: 10-Year Experience From a Single Institution

Objective: The aim of this study was to compare the early outcomes of the cone and Hetzer procedures for Ebstein's malformation.

Methods: This retrospective study included patients who underwent either cone (n = 83) or Hetzer repair (n = 45) with Ebstein's malformation from January 2011 to December 2020.

Results: One early death occurred in the cone group due to low cardiac output syndrome. Five cone and three Hetzer repair patients required reoperation before discharge. At discharge, the cone group had a better reduction in tricuspid valve regurgitation (TR) than the Hetzer group (74.7 vs. 51.1%, p = 0.009). Two patients in the cone group and seven patients in the Hetzer group required reoperation >30 days after their initial surgery. The cone group with no/mild TR was 75.6%, and the Hetzer group was 48.9% at the time of last follow-up (p = 0.010).

Conclusion: Short-term outcomes of the cone repair are better than the Hetzer procedure. The cone repair should be the better option among patients with Ebstein's malformation who need surgical intervention.

Commentary: Predictors of postoperative adverse events after cone reconstruction for Ebstein's anomaly

Prediction scores and metrics are being increasingly utilized throughout the fields of cardiothoracic and congenital cardiac surgery to identify areas for perioperative optimization or guide therapeutic intent. Here, we review a novel submission by Yang and colleagues to the Journal of Cardiac Surgery identifying preoperative factors that predict adverse postoperative outcomes from cone reconstruction for Ebstein's anomaly.