Relation of left ventricular end diastolic pressure to right ventricular end diastolic volume after operative treatment of tetralogy of fallot

The relationship between left ventricular dilation and right ventricular diastolic function in children with a patent ductus arteriosus

The impact of a dilated left ventricular (LV) on right ventricular (RV) diastolic function has not been investigated. We hypothesized that in patients with a patent ductus arteriosus (PDA), LV dilation causes elevation of the RV end-diastolic pressure (RVEDP) through ventricular-ventricular interaction. We identified patients' ages 6 months to 18 years who underwent transcatheter PDA closure at our center from 2010 to 2019. One hundred and thirteen patients were included with a median age of 3 years (0.5-18). The median LV end-diastolic dimension (LVEDD) Z-score was 1.6 (-1.4-6.3). RVEDP was positively associated with RV systolic pressure (0.38, P < 0.01), ratio of pulmonary artery/aortic systolic pressure (0.4, P < 0.01), and pulmonary capillary wedge pressure (0.71, P < 0.01). RVEDP was not associated with LVEDD Z-score (0.03, P = 0.74). In children with a PDA, RVEDP was not associated with LV dilation, but was positively associated with RV systolic pressure.

The value of myocardial strain imaging in the evaluation of patients with repaired Tetralogy of Fallot: a review of the literature

Tetralogy of Fallot (ToF) is considered to be the most common, complex, cyanotic congenital heart disease (CHD) representing 7-10% of all congenital heart defects, whereas the patients with ToF are the most frequently operated in their early infancy or childhood. Cardiac magnetic resonance (CMR) consists a valuable imaging technique for the diagnosis and serial follow-up of CHD patients. Furthermore, in recent years, advanced echocardiography imaging techniques have come to the fore, aiming to achieve a complete and more accurate evaluation of cardiac function using speckle tracking imaging modalities. We conducted a review of the literature in order to assess the myocardial deformation of patients with repaired ToF (rToF) using echocardiographic and CMR parameters. Patients with rToF have impaired myocardial strain parameters, that are well standardized either with the use of speckle tracking echocardiography or with the use of CMR imaging. Subclinical left ventricular dysfunction (low GLS) and myocardial dyssynchrony are commonly identified in rToF patients. Impaired left atrium (LA) and right atrium (RA) mechanics are, also, a common finding in this study population, but the studies using atrial strain are a lot fewer than those with LV and RV strain. No studies using myocardial work were identified in the literature, as far as rToF patients are concerned, which makes it an ideal field for further investigation.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association

Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association

Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.

Left Atrial Strain in the Repaired Tetralogy of Fallot Population: Comparisons to Biventricular Function, Native T1 Values, Exercise Parameters and Healthy Controls

BACKGROUND

Non-invasive imaging markers in patients with repaired tetralogy of Fallot (rTOF) are still being investigated to inform clinical decision making. Atrial function is a prognostic indicator in many acquired and congenital heart diseases. We sought to examine the relationship between cardiac MRI (CMR)-derived indices of left atrial (LA) function, native left ventricular (LV) T1 values, biventricular systolic function, and exercise capacity in rTOF.

METHODS

Sixty-six patients with rTOF without prior pulmonary valve replacement who underwent CMR (median age 18.5 years) were identified. Twenty-one adult rTOF patients (age range 19-32 years) were compared with 20 age-matched healthy volunteers (age range 19-34 years). LA reservoir, conduit, and pump global longitudinal strain (GLS) and strain rate (SR) were determined by tissue tracking. Native LV T1 values were measured on rTOF patients. Pearson correlations were performed to determine bivariate associations.

RESULTS

Adult rTOF patients had higher pump GLS, pump:conduit, and pump:reservoir GLS ratios, and lower conduit:reservoir GLS ratio, LV ejection fraction (EF), and right ventricular EF compared to controls (p < 0.001 for each comparison). LA conduit:reservoir GLS and pump:reservoir GLS had correlations to native LV T1 (ρ = 0.26, p = 0.03 and ρ = - 0.26, p = 0.03, respectively). LA reservoir SR had positive correlation to RV EF (ρ = 0.27, p = 0.03). There were no statistically significant correlations between LA function and exercise capacity.

CONCLUSIONS

LA function is altered in adolescent and young adult patients with rTOF indicating worse diastolic function and relates to increasing native LV T1 values. Future studies are indicated to investigate the progression of adverse atrial-ventricular interactions and poor outcomes in this population.

Relationship between right and left ventricular diastolic dysfunction assessed by 2-dimensional speckle-tracking echocardiography in adults with repaired tetralogy of Fallot

Several studies have reported a correlation between right ventricular (RV) and left ventricular (LV) systolic dysfunction in adults with repaired tetralogy of Fallot (TOF). However, data are lacking regarding the relationship between RV and LV diastolic dysfunction assessed by 2-dimensional speckle-tracking echocardiography. We studied 69 adults with repaired TOF (mean age 34 years, 61% male) who had been regularly followed up and had routinely undergone echocardiography. In addition to conventional echocardiography, global longitudinal strain (GLS) and early diastolic strain rate (SRe) of both ventricles were assessed using 2-dimensional speckle-tracking echocardiography. Results were compared with 30 age- and sex-matched controls. RV and LV GLS were decreased in TOF patients compared with controls (− 18.4 ± 3.3% vs. −23.5 ± 4.2%, p < 0.001 and − 16.0 ± 3.8% vs. −20.0 ± 3.0%, p < 0.001, respectively). RV and LV SRe were also decreased in TOF patients compared with controls (1.22 ± 0.34 sec^− 1 vs. 1.47 ± 0.41 sec^− 1, p = 0.003 and 1.29 ± 0.42 sec^− 1 vs. 1.63 ± 0.42 sec^− 1, p < 0.001, respectively). A correlation between RV and LV SRe was found in TOF patients (r = 0.43, p < 0.001) as well as between RV and LV GLS (r = 0.45, p < 0.001). Two-dimensional speckle-tracking echocardiography reveals subclinical RV and LV diastolic dysfunction in adults with repaired TOF. A correlation is observed between RV and LV diastolic dysfunction as well as between RV and LV systolic dysfunction.

Determinants and Prognostic Implications of Left-Heart Filling Pressures in Tetralogy of Fallot

BACKGROUND

Elevated pulmonary artery wedge pressure (PAWP) is the hallmark of left-heart failure and is responsible for heart failure symptoms and mortality. Although PAWP typically correlates with right atrial pressure (RAP), it is primarily dependent on left-heart myocardial properties and volume status. As right-heart disease can occur in the absence of left-heart disease in patients with tetralogy of Fallot (TOF), we hypothesized that RAP was the primary determinant of PAWP in this population.

METHODS

A cohort study of adults with TOF that underwent right-heart catheterization at Mayo Clinic Rochester (1990 to 2017) to determine the relationship among RAP, PAWP, and mortality.

RESULTS

Among 213 patients (male 105; age 37 ± 14 years), the mean PAWP was 14 ± 5 mm Hg, and RAP was 11 ± 5 mm Hg. RAP was the strongest predictor of PAWP (β = 0.68, standard error = 0.06, P < 0.001), independent of left-heart disease and atherosclerotic cardiovascular risk factors. The patients with high PAWP also had normal tissue Doppler velocities, suggesting normal left-ventricular myocardial properties. PAWP was an independent predictor of death/transplant (hazard ration [HR] 1.11, 95% confidence interval [CI], 1.03-1.20, P = 0.004). However, when RAP was incorporated into the regression model, RAP (and not PAWP) became the independent predictor of outcomes (HR 1.14, 95% CI, 1.06-1.22, P = 0.001).

CONCLUSIONS

The current study showed that RAP was the primary determinant of PAWP and accounts, to some extent, for the mortality in patients with TOF and high PAWP. The data provide new insight in the pathophysiology of disease progression for symptomatic patients with TOF.

Heightened Dependence of Left-Heart Filling Pressures on Right-Heart Failure in Congenital Heart Disease

BACKGROUND

Pulmonary artery wedge pressure (PAWP) is often elevated in patients with right-sided congenital heart disease (CHD), raising the possibility of coexisting left-heart disease, but pressure-volume relationships in the left and right sides of the heart influence one another through interdependence, which may be amplified in patients with CHD.

METHODS

We hypothesized that increases in PAWP in patients with CHD would be more strongly related to ventricular interdependence compared with patients who have isolated left-heart disease such as heart failure with preserved ejection fraction (HFpEF). Ventricular interdependence was assessed by the relationship between PAWP and right-atrial pressure (RAP), RAP/PAWP ratio, and the left-ventricular (LV) eccentricity index.

RESULTS

PAWP was elevated (≥15 mm Hg) in 49% of patients with CHD (n = 449). There was a very strong correlation between RAP and PAWP in CHD (r = 0.81, P < 0.001) that greatly exceeded the respective correlation in HFpEF (n = 160; r = 0.58, P < 0.001; P < 0.001 between groups). RAP/PAWP ratio and LV eccentricity index were higher in CHD than HFpEF (1.26 ± 0.18 vs 1.05 ± 0.14, P = 0.007) and (0.80 ± 0.21 vs 0.59 ± 0.19, P < 0.001), respectively. RAP (but not PAWP) was an independent predictor of death/transplant (hazard ratio 1.86 per 5 mm Hg, 95% confidence interval, 1.39-2.45, P = 0.002).

CONCLUSIONS

Left-heart filling pressures are commonly elevated in right-sided CHD, but this is related predominantly to right-heart failure and enhanced ventricular interdependence rather than left-heart disease. These data provide new insight into the basis of abnormal left-heart hemodynamics in patients with CHD and reinforce the importance of therapeutic interventions targeted to the right heart.

Atrial Strain Imaging after Repair of Tetralogy of Fallot: A Systematic Review

We performed a systematic review of the literature on assessment of right atrial (RA) and left atrial (LA) deformation by myocardial strain imaging in patients with repaired tetralogy of Fallot. Ten studies with a total of 536 adolescent and adult patients were included, of which 5 evaluated RA deformation, 2 studied LA deformation and 3 assessed deformation of both atria. Seven studies used speckle tracking echocardiography, 2 employed tissue Doppler imaging and 1 applied cardiac magnetic resonance feature tracking. Main findings were (i) reduced regional and/or global RA and LA strain and strain rate consistent with reduced conduit, reservoir and contractile function of the two atria in patients; (ii) associations between RA and LA deformation indices suggestive of atrial-atrial interaction; and (iii) relationships between RA deformation and indices of right ventricular systolic and diastolic function. The lack of data on prognostic value of atrial strain is an important knowledge gap.

Acute Change in Ventricular Contractility-Load Coupling After Corrective Surgery for Congenital Heart Defect: A Retrospective Cohort Study

Ventricular performance and its loading condition change drastically after surgical correction of congenital heart defect. Pressure-volume loops analysis can provide quantitative information about ventriculo-arterial coupling (VAC) indicating the interaction between ventricular contractility and loading condition. Therefore, we investigated changes in VAC after corrective surgery for ventricular septal defect (VSD)/tetralogy of Fallot (TOF), and implication of ventriculo-arterial decoupling as a prognostic factor of post-operative outcomes. In children with VSD/TOF, pre- and post-operative arterial elastance (Ea), end-systolic ventricular elastance (Ees) and VAC (Ea/Ees) were non-invasively estimated using echocardiographic parameters. Post-operative outcomes included maximum vasoactive-inotropic score, the duration of mechanical ventilation and hospital stay. Preoperatively, patients with VSD had significantly lower Ea and Ees than patients with TOF; however, VAC were preserved in both. In patients with VSD, post-operative Ea increased disproportionately to change in Ees, resulting in increased VAC. Post-operative higher VAC in patients with VSD was independently associated with maximum vasoactive-inotropic score (odds ratio [OR] 63.9; 95% Confidence Interval [CI] 4.0-553.0; P = 0.003), prolonged mechanical ventilation (OR 6.3; 95% CI 1.1-37.8; P = 0.044) and longer hospitalization (OR 17.6; 95% CI 1.6-187.0; P = 0.018). In patients with TOF, Ea and Ees reduced post-operatively; however, VAC remained unchanged and was not associated with post-operative outcomes. Despite of different loading condition, preoperative VAC maintained in both of VSD and TOF. However, particularly in VSD patients, abrupt increase in post-operative loading state induces contractility-load decoupling, which leads to worse post-operative outcomes.

Left Ventricular Stiffness in Adolescents and Young Adults with Repaired Tetralogy of Fallot

Left ventricular (LV) remodeling after tetralogy of Fallot (TOF) repair may influence LV stiffness. We hypothesized that LV stiffness is altered after TOF repair and related to myocardial calibrated integrated backscatter (cIB) and LV diastolic myocardial deformation. Seventy-seven TOF patients and 80 controls were studied. LV stiffness was assessed by diastolic wall strain (DWS) as defined by (LVPW_systole-LVPW_diastole)/LVPW_systole, where LVPW is LV posterior wall thickness, and stiffness index as defined by (E/e/LV end-diastolic dimension), where E and e are respectively early diastolic transmitral inflow and mitral annular velocities. Septal and LVPW cIB and LV diastolic strain rates were determined. Patients had significantly lower DWS (p < 0.001), higher stiffness index (p < 0.001), and greater cIB (p < 0.001). LV DWS correlated negatively with LV stiffness index (r = -0.31, p < 0.001), septal cIB (r = -0.21, p = 0.01), E/e ratio (r = -0.30, p < 0.001) and RV end-diastolic area (r = -0.31, p < 0.001), and positively with LV early (r = 0.33, p < 0.001) and late (r = 0.20, p = 0.01) diastolic strain rates and RV fractional area change (FAC) (r = 0.24, p = 0.003). Multivariate analysis revealed E/e (β = -0.26, p = 0.008), RV end-diastolic area (β = -0.20, p = 0.02), and RV FAC (β = 0.18, p = 0.01) as significant correlates of DWS. Left ventricular stiffening occurs after TOF repair and is related to impaired LV diastolic myocardial deformation, myocardial cIB, and RV volume overload.

Speckle-Tracking Echocardiographic Measures of Right Ventricular Function Correlate With Improvement in Exercise Function After Percutaneous Pulmonary Valve Implantation

BACKGROUND

Speckle-tracking echocardiographic (STE) measures of right ventricular (RV) function appear to improve after transcatheter pulmonary valve implantation (TPVI). Measures of exercise function, such as ventilatory efficiency (the minute ventilation [VE]/carbon dioxide production [VCO2] slope), have been shown to be prognostic of mortality in patients who may require TPVI. The aim of this study was to evaluate the correlation between STE measures of RV function and changes in VE/VCO2 after TPVI.

METHODS

Speckle-tracking echocardiography and cardiopulmonary exercise testing were performed at baseline and 6 months after TPVI in 24 patients from four centers. Conventional echocardiographic measures of RV function were also assessed. Echocardiographic and exercise stress test results were interpreted by single blinded observers at separate core laboratories.

RESULTS

All patients demonstrated relief of pulmonary regurgitation and stenosis after TPVI. Improvements in RV longitudinal strain (-16.9 ± 3.5% vs -19.7 ± 4.3%, P < .01) and strain rate (-0.9 ± 0.4 vs. -1.2 ± 0.4 s(-1), P < .01) were noted. The VE/VCO2 slope improved (32.4 ± 5.7 vs 31.5 ± 8.8, P = .03). No other significant echocardiographic or exercise changes were found. On multivariate regression, the change in VE/VCO2 was independently associated with change in RV longitudinal early diastolic strain rate (P < .001) and tricuspid A velocity (P < .001). Preintervention RV longitudinal strain was found to be a predictor of change in VE/VCO2 after TPVI (r = -0.60, P < .001).

CONCLUSIONS

STE measures of RV function appear to hold the potential for use as predictors of improved outcomes in patients requiring TPVI. Future studies should directly assess the prognostic significance of STE measures of RV function in this population.

Atrial mechanics after surgical repair of tetralogy of Fallot

BACKGROUND

Ventricular diastolic dysfunction in patients with repaired tetralogy of Fallot (TOF) may affect atrial mechanics. This study aimed to explore right atrial (RA) and left atrial (LA) mechanics in repaired TOF patients and their relationship with ventricular diastolic function.

METHODS

Fifty-four patients (36 males), aged 17.8 ± 8.3 years, who had undergone TOF repair at 3.9 ± 3.3 years and 40 healthy subjects aged 16.9 ± 6.3 years (P = 0.57) were studied. Right and LA peak positive, peak negative, and total strain, strain rate at ventricular systole (SRs ), early diastole (SRed ), and atrial contraction (SRac ), and electromechanical delay were determined using speckle tracking echocardiography (STE). Ventricular diastolic function was assessed by tissue Doppler imaging and STE. Ventricular volumes and pulmonary regurgitant volume were derived from 3D echocardiography.

RESULTS

Compared with controls, patients had significantly lower RA and LA peak positive and total strain, SRs , SRed , and SRac (all P < 0.001). The timing of RA (178 ± 33 msec vs. 152 ± 17 msec, P < 0.001) and LA (170 ± 32 msec vs. 152 ± 24 msec, P = 0.006) electromechanical coupling (EMC) was significantly longer in patients than in controls. The RA total strain, SRs , SRed , SRac , and EMC correlated positively with corresponding LA parameters (all P < 0.001). The RA and LA total strain and SRed were associated positively with diastolic annular velocities and strain rates of respective ventricles (all P < 0.05). The LA SRed correlated negatively with pulmonary regurgitant volume (r = -0.33, P = 0.016) and RV end-diastolic volume (r = -0.33, P = 0.015).

CONCLUSION

Mechanics of both atria are impaired in patients after repair of TOF and are associated with diastolic performance of the respective ventricles.

The relationship between longitudinal, lateral, and septal contribution to stroke volume in patients with pulmonary regurgitation and healthy volunteers

Septal systolic motion is towards the left ventricle (LV) in healthy hearts. Patients with pulmonary regurgitation (PR) and right ventricular (RV) volume overload have systolic septal motion toward the RV. This may affect the longitudinal contribution from atrioventricular plane displacement (AVPD) and septal and lateral contribution to stroke volume (SV). The study aimed to quantify these contributions to SV in patients with PR. Cardiac magnetic resonance imaging was used for assessment of cardiac volumes. Patients (n = 30; age 9-59 yr) with PR due to surgically corrected tetralogy of Fallot and 54 healthy controls (age 10-66 yr) were studied. Longitudinal contribution to RVSV was 47 ± 2% (means ± SE) in patients with PR and 79 ± 1% in controls (P < 0.001). Lateral contribution to RVSV and LVSV was 40 ± 1 and 62 ± 2% in patients and 31 ± 1 and 36 ± 1% in controls (P < 0.001 for both). Septal motion contributed to RVSV by 8 ± 1% in patients and by 7 ± 1% to LVSV in controls (P < 0.001). PR patients have decreased longitudinal contribution to RVSV and increased lateral pumping, resulting in larger outer volume changes and septal motion towards the RV. The changes in RV pumping physiology may be explained by RV remodeling resulting in lower systolic inflow of blood into the right atrium in relation to SV. This avoids the development of pendulum volume between the caval veins and right atrium, which would occur in PR patients if longitudinal contribution to SV was preserved. Decreased AVPD suggests that tricuspid annular excursion, a marker of RV function, is less valid in these patients.

Tetralogy of fallot: a surgical perspective

Tetralogy of Fallot (TOF) is an index lesion for all paediatric and congenital heart surgeons. In designing an appropriate operation for children with TOF, the predicted postoperative physiology must be taken into account, both for the short and long term. A favourable balance between pulmonary stenosis (PS) and pulmonary insufficiency (PI) may be critical for preservation of biventricular function. A unified repair strategy to limit both residual PS and PI is presented, along with supportive experimental evidence. A strategy for dealing with coronary anomalies and some comments regarding best timing of operation are also included.