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Zheng WC, Buratto E, Caldaroni F, Ishigami S, Konstantinov IE, d'Udekem Y. T-Remodeling of the Pulmonary Artery Bifurcation for Pulmonary Artery Origin Stenosis. World J Pediatr Congenit Heart Surg 2023; 14:716-722. [PMID: 37933694 DOI: 10.1177/21501351231181109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Various surgical techniques are utilized for reconstructing hypoplastic pulmonary arteries (PAs) in patients with conotruncal anomalies and at times, may be susceptible to restenosis and reoperation. We reviewed our experience with a simple technique of T-shaped remodeling of the PA bifurcation. METHODS Between 2005 and 2019, 31 patients underwent T-remodeling of central PAs by a single cardiac surgeon. The PA bifurcation was opened cranially, and the opening was augmented with an oval-shaped patch effectively transforming the V-shaped bifurcation into a T-shaped bifurcation. Both origins of the PAs were enlarged, even in the instance of single PA origin stenosis. RESULTS Median age at time of T-remodeling was 17 months (range: 7 weeks to 14 years). The following cardiac morphologies were observed: tetralogy of Fallot (n = 12, 39%), pulmonary atresia with ventricular septal defect (VSD) and major aortopulmonary collateral arteries (n = 8, 26%), truncus arteriosus (n = 6, 19%), pulmonary atresia with VSD (n = 3, 9.7%), and transposition of the great arteries (n = 2, 6.5%). Thirteen patients (42%) had previous central shunt, and eight patients (26%) had previous modified Blalock-Taussig shunt. There were no operative mortalities. Immediately after T-remodeling, echocardiographic estimates of right ventricle to PA gradient decreased from 42 [interquartile range 28-58] mm Hg to 20 [12-36] mm Hg (P = .03). Freedom from reoperation on the PA bifurcation for the entire cohort was 100% at one year, 88% (95% CI 68%-96%) at five years and 82% (57%-93%) at ten years. CONCLUSIONS T-remodeling for PA origin stenosis is a safe procedure with excellent freedom from reoperation that is easily reproducible and applicable to patients with all cardiac morphologies.
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Affiliation(s)
- Wayne C Zheng
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Department of Cardiology, Alfred Health, Melbourne, Australia
| | - Edward Buratto
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Federica Caldaroni
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Shuta Ishigami
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Igor E Konstantinov
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
| | - Yves d'Udekem
- Heart Research, Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia
- Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC, USA
- Children's National Heart Institute, Washington, DC, USA
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Bonura ED, Zhang Z, Peterson R. Incidence of branch pulmonary artery stenosis requiring intervention based on surgical repair type for tetralogy of Fallot. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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3
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Van den Eynde J, Derdeyn E, Schuermans A, Shivaram P, Budts W, Danford DA, Kutty S. End-Diastolic Forward Flow and Restrictive Physiology in Repaired Tetralogy of Fallot: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2022; 11:e024036. [PMID: 35301867 PMCID: PMC9075485 DOI: 10.1161/jaha.121.024036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Pulmonary arterial end‐diastolic forward flow (EDFF) following repaired tetralogy of Fallot has been thought to represent right ventricular (RV) restrictive physiology, but is not fully understood. This systematic review and meta‐analysis sought to clarify its physiological and clinical correlates, and to define a framework for understanding EDFF and RV restrictive physiology. Methods and Results PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for observational studies published before March 2021. Random‐effects meta‐analysis was performed to identify factors associated with EDFF. Forty‐two individual studies published between 1995 and 2021, including a total of 2651 participants (1132 with EDFF; 1519 with no EDFF), met eligibility criteria. The pooled estimated prevalence of EDFF among patients with repaired tetralogy of Fallot was 46.5% (95% CI, 41.6%–51.3%). Among patients with EDFF, the use of a transannular patch was significantly more common, and their stay in the intensive care unit was longer. EDFF was associated with greater RV indexed volumes and mass, as well as smaller E‐wave velocity at the tricuspid valve. Finally, pulmonary regurgitation fraction was greater in patients with EDFF, and moderate to severe pulmonary regurgitation was more common in this population. Conclusions EDFF is associated with dilated, hypertrophied RVs and longstanding pulmonary regurgitation. Although several studies have defined RV restrictive physiology as the presence of EDFF, our study found no clear indicators of poor RV compliance in patients with EDFF, suggesting that EDFF may have multiple causes and might not be the precise equivalent of RV restrictive physiology.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD.,Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium
| | - Emilie Derdeyn
- Faculty of Medicine and Health Sciences University of Antwerp Antwerp Belgium
| | - Art Schuermans
- Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium.,Division of Cardiovascular Medicine Radcliffe Department of Medicine Oxford Cardiovascular Clinical Research Facility University of Oxford United Kingdom
| | - Pushpa Shivaram
- Division of Pediatric Cardiology Augusta University Augusta GA
| | - Werner Budts
- Department of Cardiovascular Diseases University Hospitals Leuven and Department of Cardiovascular SciencesKU Leuven Leuven Belgium.,Congenital and Structural Cardiology UZ Leuven Leuven Belgium
| | - David A Danford
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD
| | - Shelby Kutty
- Helen B. Taussig Heart Center The Johns Hopkins Hospital and School of Medicine Baltimore MD
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4
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Cheng S, Li VWY, So EKF, Cheung YF. Right Ventricular-Pulmonary Arterial Coupling in Repaired Tetralogy of Fallot. Pediatr Cardiol 2022; 43:207-217. [PMID: 34463803 DOI: 10.1007/s00246-021-02719-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
We assessed right ventricular (RV)-pulmonary arterial (PA) coupling in patients with repaired tetralogy of Fallot (TOF). Sixty patients (34 males) aged 18.6 ± 8.3 years at 14.8 ± 7.4 years after repair and 60 controls were studied. Two-dimensional, tissue Doppler and speckle tracking echocardiography and colour flow mapping were performed to assess RV end-systolic (ESA) and -diastolic areas, tricuspid valve Doppler and myocardial velocities, left ventricular (LV) and RV deformation and pulmonary (PR), tricuspid regurgitation (TR), respectively. The ratios of RV area change to ESA and peak tricuspid annular systolic (s) velocity to RV ESA indexed to body surface area reflected RV-PA coupling. Patients had greater RV areas and reduced tricuspid annular and myocardial velocities, LV and RV myocardial mechanics compared to controls (all p < 0.05). Both RV area change/ESA ratio and peak tricuspid annular s velocity/indexed RV ESA ratio were reduced in patients (all p < 0.001). Sixty-one and 100% of patients had, respectively, RV area change/ESA ratio and peak tricuspid annular s velocity/indexed RV ESA ratio < -2SD of controls. Indices of RV-PA coupling correlated positively with tricuspid myocardial velocities, LV and RV deformation and inversely with PR and TR (all p < 0.05). Multivariate analysis showed RV systolic strain rate, PR and TR as independent predictors of both RV-PA coupling indices, whilst age, gender and LV systolic strain were also predictors of peak tricuspid annular s velocity/indexed RV ESA ratio (all p < 0.05). In conclusion, RV-PA coupling is impaired and is associated with RV and LV mechanics and severity of PR and TR in patients with repaired TOF.
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Affiliation(s)
- Sabine Cheng
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, People's Republic of China
| | - Vivian Wing-Yi Li
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, People's Republic of China
| | - Edwina Kam-Fung So
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, People's Republic of China
| | - Yiu-Fai Cheung
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, 102, Pokfulam Road, Hong Kong, People's Republic of China.
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Comparison of Patent Ductus Arteriosus Stent and Blalock-Taussig Shunt as Palliation for Neonates with Sole Source Ductal-Dependent Pulmonary Blood Flow: Results from the Congenital Catheterization Research Collaborative. Pediatr Cardiol 2022; 43:121-131. [PMID: 34524483 DOI: 10.1007/s00246-021-02699-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 07/23/2021] [Indexed: 12/19/2022]
Abstract
Patent ductus arteriosus (PDA) stenting is an accepted method for securing pulmonary blood flow in cyanotic neonates. In neonates with pulmonary atresia and single source ductal-dependent pulmonary blood flow (SSPBF), PDA stenting remains controversial. We sought to evaluate outcomes in neonates with SSPBF, comparing PDA stenting and surgical Blalock-Taussig shunt (BTS). Neonates with SSPBF who underwent PDA stenting or BTS at the four centers of the Congenital Catheterization Research Collaborative from January 2008 to December 2015 were retrospectively reviewed. Reintervention on the BTS or PDA stent prior to planned surgical repair served as the primary endpoint. Additional analyses of peri-procedural complications, interventions, and pulmonary artery growth were performed. A propensity score was utilized to adjust for differences in factors. Thirty-five patients with PDA stents and 156 patients with BTS were included. The cohorts had similar baseline characteristics, procedural complications, and mortality. Interstage reintervention rates were higher in the PDA stent cohort (48.6% vs. 15.4%, p < 0.001).
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Voges I, Al-Mallah MH, Scognamiglio G, Di Salvo G. Right Heart-Pulmonary Circulation Unit in Congenital Heart Diseases. Heart Fail Clin 2018; 14:283-295. [PMID: 29966627 DOI: 10.1016/j.hfc.2018.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The right ventricle plays a major role in congenital heart disease. This article describes the right ventricular mechanics in some selected congenital heart diseases affecting the right ventricle in different ways: tetralogy of Fallot, Ebstein anomaly, and the systemic right ventricle.
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Affiliation(s)
- Inga Voges
- Royal Brompton and Harefield Trust, London, UK
| | - Mouaz H Al-Mallah
- National Guard Health Affairs, Riyadh King Abdulaziz Cardiac Center, Riyadh, Saudi Arabia
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D'Souza GA, Banerjee RK, Taylor MD. Evaluation of pulmonary artery stenosis in congenital heart disease patients using functional diagnostic parameters: An in vitro study. J Biomech 2018; 81:58-67. [PMID: 30293825 DOI: 10.1016/j.jbiomech.2018.09.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 07/23/2018] [Accepted: 09/13/2018] [Indexed: 02/03/2023]
Abstract
Congenital pulmonary artery (PA) stenosis is often associated with abnormal PA hemodynamics including increased pressure drop (Δp) and reduced asymmetric flow (Q), which may result in right ventricular dysfunction. We propose functional diagnostic parameters, pressure drop coefficient (CDP), energy loss (Eloss), and normalized energy loss (E¯loss) to characterize pulmonary hemodynamics, and evaluate their efficacy in delineating stenosis severity using in vitro experiments. Subject-specific test sections including the main PA (MPA) bifurcating into left and right PAs (LPA, RPA) with a discrete LPA stenosis were manufactured from cross-sectional imaging and 3D printing. Three clinically-relevant stenosis severities, 90% area stenosis (AS), 80% AS, and 70% AS, were evaluated at different cardiac outputs (COs). A benchtop flow loop simulating pulmonary hemodynamics was used to measure Q and Δp within the test sections. The experimental Δp-Q characteristics along with clinical data were used to obtain pathophysiologic conditions and compute the diagnostic parameters. The pathophysiologic QLPA decreased as the stenosis severity increased at a fixed CO. CDPLPA, Eloss,LPA (absolute), and E¯loss,LPA (absolute) increased with an increase in LPA stenosis severity at a fixed CO. Importantly, CDPLPA and E¯loss,LPA had reduced variability with CO, and distinct values for each LPA stenosis severity. Under variable CO, a) CDPLPA values were 14.5-21.0 (70% AS), 60.7- 2.2 (80% AS), ≥ 261.6 (90% AS), and b) E¯loss,LPA values (in mJ per QLPA) were -501.9 to -1023.8 (70% AS), -1247.6 to -1773.0 (80% AS), -1934.5 (90% AS). Hence, CDPLPA and E¯loss,LPA are expected to assess the true functional severity of PA stenosis.
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Affiliation(s)
- Gavin A D'Souza
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, USA
| | - Rupak K Banerjee
- Department of Mechanical and Materials Engineering, University of Cincinnati, Cincinnati, OH, USA.
| | - Michael D Taylor
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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8
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Utility of Cardiac Magnetic Resonance Imaging in the Management of Adult Congenital Heart Disease. J Thorac Imaging 2017. [DOI: 10.1097/rti.0000000000000280] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Rutz T, Meierhofer C, Naumann S, Martinoff S, Ewert P, Stern HC, Fratz S. Comparison of MR flow quantification in peripheral and main pulmonary arteries in patients after right ventricular outflow tract surgery: A retrospective study. J Magn Reson Imaging 2017; 46:1839-1845. [PMID: 28301100 DOI: 10.1002/jmri.25701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/24/2017] [Indexed: 11/11/2022] Open
Abstract
PURPOSE To compare the quantification of pulmonary stroke volume (SV) by phase contrast magnetic resonance (PC-MR) in the main pulmonary artery (MPA) to the sum of SVs in both peripheral pulmonary arteries (PPA) in different right ventricular (RV) outflow pathologies. MATERIALS AND METHODS Pulmonary SV was determined by PC-MR in the MPA and the PPA in healthy individuals (H, n = 54), patients after correction for tetralogy of Fallot with significant pulmonary regurgitation and without pulmonary or RV outflow tract stenosis (PR, n = 50), and in patients with RV outflow tract or pulmonary valve stenosis (PS, n = 50). Resulting SVs were compared to aortic SV in the ascending aorta. RESULTS Mean age was similar between the groups: H 28 ± 17 vs. PR 24 ± 11 vs. PS 22 ± 10 years. Bland-Altman analyses revealed in all groups a relatively small systemic (bias) but large random error (limits of agreement) for pulmonary SV determined in the MPA as compared to summed SVs in the PPA. The largest limits of agreement were present in PS patients: H: MPA 3.9% (-11, + 19) vs. PPA 0.4% (-15, + 15); PR: MPA 5.2% (-25, + 36) vs. PPA 0.6% (-24, + 26); PS: MPA 5% (-36; + 46), PPA -0.03% (-34, + 35). CONCLUSION The accuracy of PC-MR in the MPA is reasonable; however, a large random error (precision) is observed that is most pronounced in PS patients. This potential error should be taken into consideration when interpreting MPA flow measurements. LEVEL OF EVIDENCE 3 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2017;46:1839-1845.
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Affiliation(s)
- Tobias Rutz
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany.,Service of Cardiology, Centre hospitalier universitaire vaudois, Lausanne, Switzerland
| | - Christian Meierhofer
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
| | - Susanne Naumann
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
| | - Stefan Martinoff
- Department of Radiology, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
| | - Peter Ewert
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
| | - Heiko C Stern
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
| | - Sohrab Fratz
- Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, Munich, Germany
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Cui C, Liu L, Fan T, Peng B, Cheng Z, Ge Z, Li Y, Liu Y, Zhang Y, Ai F, Zhang L. Application of Real-Time Three-Dimensional Echocardiography to Evaluate the Pre- and Postoperative Right Ventricular Systolic Function of Patients with Tetralogy of Fallot. ACTA CARDIOLOGICA SINICA 2016; 31:345-52. [PMID: 27122891 DOI: 10.6515/acs20150318a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
UNLABELLED Tetralogy of Fallot (ToF) can be challenging for clinicians to both diagnose and treat, given the multiple heart defects that are by definition associated with the illness. This study investigates the value of real-time three- dimensional echocardiography (RT-3DE) in evaluating the pre-and postoperative right ventricular systolic function of patients with tetralogy of Fallot. A total of 41 ToF patients were divided into two groups: the child group (CG) and the adult group (AG) according to age. The right ventricular end-diastolic volume (RVEDV), right ventricular end-systolic volume (RVESV), and the right ventricular ejection fraction (RVEF) of ToF patients were measured before surgery, 7 days, and 3 months after the surgery. The correlation between the preoperative Nakata index and RVEF was then analyzed. Compared with the RVEDV and RVESV prior to surgery, those of the postoperative 7-day and 3-month were not statistically significant (p > 0.05). However, RVEF decreased, and the difference was statistically significant (p < 0.05). The differences in RVEDV, RVESV, and RVEF between postoperative 3-month and 7-day were not significant (p > 0.05). Compared with the pre-and postoperative RVEDV and RVESV of CG, those of AG increased. However, RVEF decreased, and the differences were statistically significant (p < 0.05). Our study indicated that the correlation between preoperative Nakata index and RVEF was good. Ultimately, we did confirm that RT-3DE can quantitatively evaluate the right ventricular volume and systolic function of ToF patients, thereby providing clinical significance in determining postoperative efficacy and prognosis evaluation. KEY WORDS Echocardiography; Right; Tetralogy of Fallot; Three-dimensional; Ventricular function.
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Affiliation(s)
- Cunying Cui
- Department of Cardiovascular Ultrasonography
| | - Lin Liu
- Department of Cardiovascular Ultrasonography
| | - Taibing Fan
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Bangtian Peng
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Zhaoyun Cheng
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Zhenwei Ge
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Yanan Li
- Department of Cardiovascular Ultrasonography
| | | | - Yanwei Zhang
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
| | - Feng Ai
- Children's Heart Center, Henan Provincial People's Hospital, Zhengzhou 450003, China
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Harris MA, Avitabile CM, Fu GL, Kim DW, Kim TS, Gillespie MJ, Keller MS, Fogel MA, Whitehead KK. Accuracy and Internal Consistency of Cardiac Magnetic Resonance Imaging in Measuring Branch Pulmonary Artery Flows in Patients With Conotruncal Anomalies and Branch Pulmonary Artery Stents. Am J Cardiol 2016; 117:1160-6. [PMID: 26993977 DOI: 10.1016/j.amjcard.2016.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 01/07/2016] [Accepted: 01/07/2016] [Indexed: 10/22/2022]
Abstract
Clinicians use branch pulmonary artery (BPA) blood flow distribution to help determine the need for intervention. Although phase-contrast magnetic resonance (PCMR) flow measurements are accurate, this has never been shown in the vicinity of a BPA ferromagnetic stent (FS) which produces significant susceptibility artifact. We retrospectively reviewed 49 consecutive PCMR studies performed from 2005 to 2012 on patients with repaired conotruncal anomalies and either left (n = 29) or right PA (n = 20) stents. Three methods of measuring the stented BPA flow were compared: (1) main PA (MPA) minus nonstented BPA, (2) direct PCMR of stented BPA away from the artifact, and (3) pulmonary venous flows (ipsilateral to stented BPA and derived pulmonary blood flow ratio from bilateral pulmonary venous flows). Internal consistency was tested with the Student t test, linear regression, Bland-Altman analysis, and intraclass correlation (ICC). The mean age was 11.7 ± 6.9 years with 5.8 ± 4.2 years between stent placement and CMR. There was good agreement without significant difference between MPA-derived stented BPA flow (method 1) and direct PCMR of stented BPA (method 2; 41 ± 19% vs 39 ± 19%, p = 0.59; R(2) = 0.84, p <0.001; ICC = 0.96). There was also good agreement between methods 1 and 2 compared to pulmonary venous flows, with the highest correlation occurring between method 2 and ipsilateral pulmonary venous flow (R(2) = 0.90, p <0.001; ICC = 0.97 for MPA-derived-stented BPA flow; R(2) = 0.94, p <0.001; ICC = 0.98 for direct PCMR of stented BPA). Eleven of the 49 patients (22%) underwent interventional catheterization after PCMR. In conclusion, in the vicinity of a BPA FS, accurate measurement of the net fractional pulmonary blood flow ratio is feasible. PCMR adjacent to the stent and ipsilateral pulmonary venous flows provide the most internally consistent data. These data underscore PCMR's utility in managing patients with implanted FS.
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12
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Shin YR, Jung JW, Kim NK, Choi JY, Kim YJ, Shin HJ, Park YH, Park HK. Factors associated with progression of right ventricular enlargement and dysfunction after repair of tetralogy of Fallot based on serial cardiac magnetic resonance imaging. Eur J Cardiothorac Surg 2016; 50:464-9. [DOI: 10.1093/ejcts/ezw049] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 01/11/2016] [Indexed: 02/06/2023] Open
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13
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Wilder TJ, Van Arsdell GS, Pham-Hung E, Gritti M, Hussain S, Caldarone CA, Redington A, Hickey EJ. Aggressive Patch Augmentation May Reduce Growth Potential of Hypoplastic Branch Pulmonary Arteries After Tetralogy of Fallot Repair. Ann Thorac Surg 2016; 101:996-1004. [PMID: 26830224 DOI: 10.1016/j.athoracsur.2015.11.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Revised: 11/10/2015] [Accepted: 11/13/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Potential surgical strategies for hypoplastic branch pulmonary arteries (BPAs) during tetralogy of Fallot repair include (1) extensive patch augmentation to the hilum (PATCH), (2) limited extension arterioplasty to the proximal pulmonary artery (EXTENSION), or (3) leaving the native vessels unaugmented (NATIVE). We explored the effect of these strategies on reintervention and BPA growth. METHODS From 2000 to 2012, 434 children underwent complete tetralogy of Fallot repair. Risk-adjusted parametric models were used to analyze the risk of BPA reintervention for (1) all children, (2) children with BPAs of 4 mm or smaller, and (3) children with BPAs of 3 mm or smaller. Repeated-measures analysis of more than 2,000 echocardiograms was used to characterize postoperative BPA growth and right ventricular pressure by using nonlinear mixed models. RESULTS Overall survival (99% [3 deaths]) was excellent. The 10-year freedom from BPA reintervention was 84%. In risk-adjusted models (including baseline BPA z-score), PATCH had a decreased freedom from reintervention (73%; p < 0.01) vs EXTENSION (87%) or NATIVE (91%). For children with BPAs of 4 mm or smaller (28 PATCH, 60 EXTENSION, 75 NATIVE), baseline characteristics were similar. The risk-adjusted 5-year freedom from reintervention was 68% for PATCH, 76% for EXTENSION, and 85% for NATIVE. PATCH trended toward an increased risk of reintervention (p = 0.07). For children with BPAs of 4 mm or smaller left in their NATIVE state, only ∼15% required reintervention. After adjustment for baseline BPA z-score, the time-related BPA growth was decreased (p < 0.014) and right ventricular pressure was increased (p = 0.03) for the PATCH group. CONCLUSIONS Aggressive PATCH augmentation of hypoplastic BPAs improves the short-term geometry but may lead to late stenosis and higher rates of reintervention. Hypoplastic BPAs in tetralogy of Fallot tend (∼85%) to grow well without instrumentation.
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Affiliation(s)
- Travis J Wilder
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Pham-Hung
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Michael Gritti
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sara Hussain
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher A Caldarone
- Division of Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrew Redington
- Department of Pediatric Cardiology, the Heart Institute at Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Edward J Hickey
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Chan SS, Whitehead KK, Kim TS, Fu GL, Keller MS, Fogel MA, Harris MA. Repaired tetralogy of Fallot with coexisting unrepaired partial anomalous pulmonary venous connection is associated with diminished right ventricular ejection fraction and more severe right ventricular dilation. Pediatr Radiol 2015; 45:1465-71. [PMID: 25935212 DOI: 10.1007/s00247-015-3358-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Revised: 03/14/2015] [Accepted: 04/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND There is an established association between tetralogy of Fallot and partial anomalous pulmonary venous connections. This association is important because surgically repaired tetralogy patients have increased risk of right heart failure. We hypothesize that partial anomalous venous connections increase right ventricular volumes and worsen right ventricular failure. MATERIALS AND METHODS We reviewed cardiac MRI exams performed at a tertiary pediatric hospital from January 2005 to January 2014. We identified patients with repaired tetralogy and unrepaired partial anomalous pulmonary venous connection. We used age- and gender-matched repaired tetralogy patients without partial anomalous pulmonary venous connection as controls. We analyzed the MRI results and surgical course and performed comparative statistics to identify group differences. RESULTS There were eight patients with repaired tetralogy and unrepaired partial anomalous pulmonary venous connection and 16 controls. In all cases, the partial anomalous pulmonary venous connection was not detected on preoperative echocardiography. There were no significant differences in surgical course and body surface area between the two groups. Repaired tetralogy patients with unrepaired partial anomalous pulmonary venous connection showed significantly higher indexed right ventricular end diastolic volume (149 ± 33 mL/m(2) vs. 118 ± 30 mL/m(2)), right ventricle to left ventricle size ratios (3.1 ± 1.3 vs. 1.9 ± 0.5) and a higher incidence of reduced right ventricular ejection fraction compared to controls (3/8 vs. 0/16). CONCLUSION Repaired tetralogy of Fallot with unrepaired partial anomalous pulmonary venous connection is associated with reduced right ventricular ejection fraction and more significant right ventricular dilation.
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Affiliation(s)
- Sherwin S Chan
- Department of Radiology, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA,
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15
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Maskatia SA, Morris SA, Spinner JA, Krishnamurthy R, Altman CA. Echocardiographic Parameters of Right Ventricular Diastolic Function in Repaired Tetralogy of Fallot Are Associated with Important Findings on Magnetic Resonance Imaging. CONGENIT HEART DIS 2015; 10:E113-22. [PMID: 25916551 DOI: 10.1111/chd.12265] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Right ventricular (RV) dilation, RV dysfunction, RV outflow tract obstruction, and branch pulmonary artery stenosis are risk factors associated with the need for future surgical or catheter-based intervention commonly assessed by cardiac magnetic resonance in patients with tetralogy of Fallot who have undergone initial repair. The ability of echocardiography to predict the presence of these risk factors is limited. OBJECTIVE We aimed to determine the association between echocardiographic parameters of right ventricular diastolic dysfunction and risk factors for intervention as identified on cardiac magnetic resonance imaging (CMR). DESIGN We reviewed all echocardiograms and CMRs performed at our institution within 1 year of each other in patients with repaired tetralogy of Fallot. We evaluated patients for the following: RV systolic dysfunction (RV ejection fraction <45%), RV dilation (right ventricular end-diastolic volume ≥ 160 mL/m(2)), and RV obstruction (RV outflow tract gradient ≥ 3 m/s by echocardiogram or branch pulmonary artery stenosis assessed by CMR). We evaluated for associations between the above CMR findings and echocardiographic parameters of diastolic function. RESULTS CMR and echocardiographic images performed between March 2007 and March 2012 were available in 99 patients. RV obstruction was associated with lower E/A ratio (P = .02), E/A reversal (P = .02), and prograde end diastolic pulmonary flow (P < .01). Low tricuspid annular a' and low septal s' were associated with lower RV ejection fraction (P < .01, P < .01). Elevated E/e' was associated with higher RV end diastolic volume (P = .04). In predicting the presence of any of the evaluated risk factors for future intervention, TV E/e' ≥ 4.7 had positive predictive value (PPV) of 86% and negative predictive value (NPV) of 50%, TV E/A reversal had PPV of 89% and NPV of 34, and prograde end diastolic pulmonary flow on echocardiogram had PPV of 91% and NPV of 38%. CONCLUSIONS Echocardiographic parameters of diastolic dysfunction have a reasonable PPV but poor NPV for predicting clinically significant risk factors identified by CMR.
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Affiliation(s)
- Shiraz A Maskatia
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Shaine A Morris
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Joseph A Spinner
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Rajesh Krishnamurthy
- Department of Radiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
| | - Carolyn A Altman
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
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Lee C, Lee CH, Kwak JG, Kim SH, Shim WS, Lee SY, Jang SI, Park SJ, Kim YM. Factors associated with right ventricular dilatation and dysfunction in patients with chronic pulmonary regurgitation after repair of tetralogy of Fallot: analysis of magnetic resonance imaging data from 218 patients. J Thorac Cardiovasc Surg 2014; 148:2589-95. [PMID: 25173118 DOI: 10.1016/j.jtcvs.2014.07.051] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 07/09/2014] [Accepted: 07/14/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the present study was to identify the factors associated with right ventricular (RV) dilatation and dysfunction in patients with chronic pulmonary regurgitation (PR) after repair of tetralogy of Fallot. METHODS From April 2002 to June 2013, 218 patients with repaired tetralogy of Fallot underwent magnetic resonance imaging; 165 (76%) underwent transannular repair and 36 (17%) underwent nontransannular repair. Linear regression analyses were used to identify the predictors for RV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction. RESULTS On univariable analysis, male sex, ventricular septal defect (VSD) closure through the right ventricle, larger pulmonary artery index, and greater PR fraction were associated with greater RV volume indexes. Multivariable analyses identified male sex (β = 17.55, P < .001 for RV EDVI; β = 14.08, P = .001 for RV ESVI), VSD closure through RV (β = 8.49, P = .048 for RV ESVI), longer interval since repair (β = 1.29, P = .014 for RV EDVI), and greater PR fraction (β = 1.92, P < .001 for RV EDVI; β = 1.38, P < .001 for RV ESVI) as independent predictors for greater RV volume indexes. On univariable analysis, male sex, VSD closure through the right ventricle, and greater PR fraction were associated with a lower RV ejection fraction. Multivariable analysis identified male sex (β = -3.10, P = .018), VSD closure through the right ventricle (β = -3.05, P = .020), and greater PR fraction (β = -0.27, P < .001) as independent predictors for a lower RV ejection fraction. CONCLUSIONS Male sex, VSD closure through the right ventricle, longer interval since repair, and greater PR fraction were independent predictors of RV dilatation after tetralogy of Fallot repair. Male sex, VSD closure through the right ventricle, and greater PR fraction were also independent predictors of RV dysfunction.
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Affiliation(s)
- Cheul Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea.
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Seong-Ho Kim
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Woo-Sup Shim
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Sang Yun Lee
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - So-Ick Jang
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Su-Jin Park
- Department of Pediatric Cardiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
| | - Yang Min Kim
- Department of Radiology, Cardiovascular Center, Sejong General Hospital, Bucheon, Republic of Korea
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17
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Chen CA, Chen SY, Wang JK, Tseng WYI, Chiu HH, Chang CI, Chiu IS, Chen YS, Yang MC, Lu CW, Lin MT, Wu MH. Ventricular geometric characteristics and functional benefit of mild right ventricular outflow tract obstruction in patients with significant pulmonary regurgitation after repair of tetralogy of Fallot. Am Heart J 2014; 167:555-61. [PMID: 24655705 DOI: 10.1016/j.ahj.2013.12.026] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 12/28/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Right ventricular (RV) outflow tract obstruction (RVOTO) might protect the RV from adverse remodeling caused by significant pulmonary regurgitation (PR) in patients with repaired tetralogy of Fallot (rTOF), but the underlying mechanisms and influences on exercise tolerance remain unclear. This study sought to investigate the impacts from mild RVOTO on ventricular remodeling and exercise capacity in rTOF. METHODS Eighty-five rTOF patients with a PR fraction ≥20% were assessed with cardiac magnetic resonance, cardiopulmonary exercise test, and echocardiography. Patients with a peak RVOT pressure gradient 20-50 mmHg were considered to have mild RVOTO (n = 29), while those with a gradient <20 mmHg had isolated PR (n = 56). RESULTS Comparing to patients with isolated PR, patients with combined PR and mild RVOTO had smaller RV and RVOT dimension, better RV and left ventricular (LV) ejection fraction (EF), and superior exercise capacity. PR severity and RV mass/volume ratio were similar between these 2 groups. LVEF coupled with RVEF only in patients with isolated PR. In multivariate analysis, smaller RVOT dimension was independently related to smaller RV dimension (P < .001) and higher RVEF (P = .005). Furthermore, mild RVOTO was independently associated with higher peak oxygen consumption (P = .014) and oxygen uptake efficiency slope (P = .005). CONCLUSIONS Patients with combined PR and mild RVOTO had better RV remodeling and exercise capacity compared to those with isolated PR. Our findings confirm the benefits from mild residual RVOTO support a policy of conservative RVOTO relief at repair.
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Affiliation(s)
- Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ssu-Yuan Chen
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Yih Isaac Tseng
- Center for Optoelectronic Biomedicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsin-Hui Chiu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chung-I Chang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ing-Sh Chiu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chun Yang
- Department of Pediatrics, E-DA hospital and I-SHOU University, Kaohsiung, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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