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Avesani M, Jalal Z, Friedberg MK, Villemain O, Venet M, Di Salvo G, Thambo JB, Iriart X. Adverse remodelling in tetralogy of Fallot: From risk factors to imaging analysis and future perspectives. Hellenic J Cardiol 2024; 75:48-59. [PMID: 37495104 DOI: 10.1016/j.hjc.2023.07.008] [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] [Received: 02/20/2023] [Revised: 05/29/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023] Open
Abstract
Although contemporary outcomes of initial surgical repair of tetralogy of Fallot (TOF) are excellent, the survival of adult patients remains significantly lower than that of the normal population due to the high incidence of heart failure, ventricular arrhythmias, and sudden cardiac death. The underlying mechanisms are only partially understood but involve an adverse biventricular response, so-called remodelling, to key stressors such as right ventricular (RV) pressure-and/or volume-overload, myocardial fibrosis, and electro-mechanical dyssynchrony. In this review, we explore risk factors and mechanisms of biventricular remodelling, from histological to electro-mechanical aspects, and the role of imaging in their assessment. We discuss unsolved challenges and future directions to better understand and treat the long-term sequelae of this complex congenital heart disease.
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Affiliation(s)
- Martina Avesani
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France; Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Zakaria Jalal
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Mark K Friedberg
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Villemain
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maeyls Venet
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giovanni Di Salvo
- Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Jean-Benoît Thambo
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Xavier Iriart
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France.
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Dasgupta MN, Kaplinski MA, Reddy CD, Collins RT. Patterns of Aortic Dilation in Tetralogy of Fallot: An Analysis of 100 Fetal Echocardiograms Compared With Matched Controls. J Am Heart Assoc 2023; 12:e030083. [PMID: 37929767 PMCID: PMC10727408 DOI: 10.1161/jaha.123.030083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 10/09/2023] [Indexed: 11/07/2023]
Abstract
Background Although aortic dilation is common in tetralogy of Fallot (TOF), its progression and risk of dissection are not well understood. The mechanism of dilation is primarily attributed to increased flow in utero; an alternative is unequal septation of the truncus arteriosus resulting in a larger aorta and inherently hypoplastic pulmonary artery (PA). If the latter is true, we hypothesize the aorta to PA ratio in TOF is stable throughout gestation, and sums of great artery dimensions are similar to controls. Methods and Results We performed a single-center retrospective study of fetuses with TOF (2014-2020) and matched controls. We compared sums of diameters, circumferences, and cross-sectional areas of the aorta and PA and evaluated the aorta to PA ratio across gestation in 2 TOF subtypes: pulmonary stenosis and atresia (TOF-PA). There were 100 echocardiograms with TOF (36% TOF-PA) with median gestational age of 31 weeks (interquartile range 26.5-34.4) and median maternal age of 34 years (interquartile range 30-37). There were no differences in sums of great artery dimensions between TOF-pulmonary stenosis and controls. In TOF-PA, sums were significantly lower than controls (P values <0.01). The aorta to PA ratio was stable throughout gestation (Pearson's r=0.08 [95% CI, -0.12 to 0.27], -0.06 [95% CI, -0.25 to 0.14]). Conclusions The aorta in fetal TOF is large but grows proportionally throughout gestation, with sums of great artery dimensions similar to controls. TOF-PA appears distinct from TOF-pulmonary stenosis (with smaller sums), warranting further investigation. In conclusion, our findings suggest an intrinsic developmental mechanism contributes to aortic dilation in TOF.
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Affiliation(s)
- Minnie N. Dasgupta
- Department of Pediatrics (Division of Cardiology)Stanford University School of MedicinePalo AltoCAUSA
| | - Michelle A. Kaplinski
- Department of Pediatrics (Division of Cardiology)Stanford University School of MedicinePalo AltoCAUSA
| | - Charitha D. Reddy
- Department of Pediatrics (Division of Cardiology)Stanford University School of MedicinePalo AltoCAUSA
| | - R. Thomas Collins
- Department of Pediatrics (Division of Cardiology)University of Kentucky College of MedicineLexingtonKYUSA
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Kim W, Kwak JG, Cho S, Kim WH. Ten-year follow-up of dilatation of aortic structures in Fallot-type anomalies. Pediatr Cardiol 2023; 44:1552-1559. [PMID: 37405457 DOI: 10.1007/s00246-023-03225-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 06/28/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVES Dilatation of the aortic root structures or ascending aorta is often observed in patients with Fallot-type anomalies. We aimed to determine the dilation rate of the aortic structures and investigate strategies for managing this phenomenon. METHODS In this retrospective study, we enrolled 66 out of 801 patients who underwent corrective surgery for Fallot-type anomalies (tetralogy of Fallot [TOF] and Fallot-type double outlet right ventricle [DORV]) between 2004 and 2020. These 66 patients had follow-up cardiac computed tomography (CT) angiography images taken at least 5 years after the initial CT study. We analyzed the diameters and aortic cross-sectional area/height ratio (AH) of the aortic annulus, sinus of Valsalva, sinotubular junction, and ascending aorta between the initial and follow-up CT scans. "Dilatation" was defined as a z-score over 2 for each aortic structure. RESULTS The median age at the initial and follow-up CT scans was 5.9 years (interquartile range [IQR]: 0.4 ~ 12.4) and 15.9 years (IQR 9.3 ~ 23.4), respectively. The median CT interval (from initial to latest CT) was 9.5 years (IQR 6.6 ~ 12.0). The sinus of Valsalva exhibited the most significant dilation (32.8 mm at follow-up CT) over the study period. The AH ratio increased significantly in all four aortic structures. The patient's age was significantly associated with higher AH in the follow-up CT. Aortic dilatation was present in 74.2% of patients at the initial CT and increased to 86.4% at the follow-up CT. CONCLUSION In Fallot-type anomalies, the AH ratio of aortic root structures significantly increased over an average period of approximately 9.5 years. The number of patients diagnosed with aortic dilatation also increased. Based on our observations in this study, these patients' group should be considered for more frequent follow-up examinations, as significant dilatation could occur in their mid-20 s.
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Affiliation(s)
- Woojung Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Children's Hospital, Seoul National University, 101 Daehak-Ro, Chongno-Gu, Seoul, 03080, Republic of Korea
- Department of Thoracic and Cardiovascular Surgery, Korean Armed Forces Capital Hospital, Seongnam, Republic of Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Children's Hospital, Seoul National University, 101 Daehak-Ro, Chongno-Gu, Seoul, 03080, Republic of Korea.
| | - Sungkyu Cho
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Children's Hospital, Seoul National University, 101 Daehak-Ro, Chongno-Gu, Seoul, 03080, Republic of Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Seoul National University Children's Hospital, Seoul National University, 101 Daehak-Ro, Chongno-Gu, Seoul, 03080, Republic of Korea
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Lyon SM, Ofner S, Cheng P, Powell S, Schloss D, Landis BJ, Cook S, Herrmann JL, Patel JK. Serial Magnetic Resonance Imaging for Aortic Dilation in Tetralogy of Fallot With Pulmonary Stenosis. Am J Cardiol 2023; 191:92-100. [PMID: 36669383 PMCID: PMC10337873 DOI: 10.1016/j.amjcard.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/12/2022] [Accepted: 12/18/2022] [Indexed: 01/20/2023]
Abstract
Aortic dilation occurs in patients with repaired tetralogy of Fallot (TOF), but the rate of growth is incompletely characterized. The aim of this study was to assess the rates of growth of the aortic root and ascending aorta in a cohort of pediatric and adult patients with sequential magnetic resonance angiography Magnetic Resonance Imaging (MRI) data. Using serial MRI data from pediatric and adult patients with repaired TOF, we performed a retrospective analysis of the rates of growth and associations with growth of the aortic root and ascending aorta. Patients with pulmonary atresia or absent pulmonary valve were excluded. Between years 2005 to 2021, a total of 99 patients were enrolled. A follow-up MRI was performed an average of 5.9 ± 3.7 years from the initial study. For the cohort aged ≥16 years, the mean rate of change in diameter was 0.2 ± 0.5 mm/year at the ascending aorta and 0.2 ± 0.6 mm/year at the sinus of Valsalva. For the entire cohort, the mean change in cross-sectional area indexed to height at the ascending aorta was 7 ± 12 mm2/m/year and at the sinus of Valsalva was 10 ± 16 mm2/m/year. Younger age was associated with higher rates of growth of the sinus of Valsalva while the use of β blockers or angiotensin-converting enzyme inhibitors was associated with a slower rate of growth. There were no cases of aortic dissection in this cohort. We conclude that serial MRI demonstrates a slow rate of growth of the aorta in the TOF.
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Affiliation(s)
- Shannon M Lyon
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts.
| | - Susan Ofner
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine and Richard M. Fairbanks School of Public Health, Indianapolis, Indiana
| | - Phillip Cheng
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Shannon Powell
- Division of Cardiology, Department of Pediatrics, LSU Health Sciences Center, Children's Hospital New Orleans, New Orleans, Louisiana
| | - Daniel Schloss
- Department of Emergency Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Benjamin J Landis
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen Cook
- Krannert Institute of Cardiology and the IU Health Adult Congenital Heart Disease Program, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis Indiana
| | - Jyoti K Patel
- Division of Cardiology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
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Zhang S, Liu H, Wang X, Huang S, Zhang C. The Surgical Strategy for Progressive Dilatation of Aortic Root and Aortic Regurgitation After Repaired Tetralogy of Fallot: A Case Report. Front Cardiovasc Med 2022; 9:840946. [PMID: 35592402 PMCID: PMC9110687 DOI: 10.3389/fcvm.2022.840946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
It has been found that postoperative progressive dilatation of aortic root is not rare for adult patients with repaired Tetralogy of Fallot (TOF), which leads to severe aortic regurgitation or even fatal dissection. Therefore, clinically, surgical treatment for both regurgitated aortic valve and dilated root is needed based on preoperative assessments and individual treatment strategies.
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