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Heng EL, Gatzoulis MA, Uebing A, Sethia B, Uemura H, Smith GC, Diller GP, McCarthy KP, Ho SY, Li W, Wright P, Spadotto V, Kilner PJ, Oldershaw P, Pennell DJ, Shore DF, Babu-Narayan SV. Immediate and Midterm Cardiac Remodeling After Surgical Pulmonary Valve Replacement in Adults With Repaired Tetralogy of Fallot: A Prospective Cardiovascular Magnetic Resonance and Clinical Study. Circulation 2017; 136:1703-1713. [PMID: 29084778 PMCID: PMC5662153 DOI: 10.1161/circulationaha.117.027402] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 09/28/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot provides symptomatic benefit and right ventricular (RV) volume reduction. However, data on the rate of ventricular structural and functional adaptation are scarce. We aimed to assess immediate and midterm post-PVR changes and predictors of reverse remoeling. METHODS Fifty-seven patients with repaired tetralogy of Fallot (age ≥16 y; mean age, 35.8±10.1 y; 38 male) undergoing PVR were prospectively recruited for cardiovascular magnetic resonance performed before PVR (pPVR), immediately after PVR (median, 6 d), and midterm after PVR (mPVR; median, 3 y). RESULTS There were immediate and midterm reductions in indexed RV end-diastolic volumes and RV end-systolic volumes (RVESVi) (indexed RV end-diastolic volume pPVR versus immediately after PVR versus mPVR, 156.1±41.9 versus 104.9±28.4 versus 104.2±34.4 mL/m2; RVESVi pPVR versus immediately after PVR versus mPVR, 74.9±26.2 versus 57.4±22.7 versus 50.5±21.7 mL/m2; P<0.01). Normal postoperative diastolic and systolic RV volumes (the primary end point) achieved in 70% of patients were predicted by a preoperative indexed RV end-diastolic volume ≤158 mL/m2 and RVESVi ≤82 mL/m2. RVESVi showed a progressive decrease from baseline to immediate to midterm follow-up, indicating ongoing intrinsic RV functional improvement after PVR. Left ventricular ejection fraction improved (pPVR versus mPVR, 59.4±7.6% versus 61.9±6.8%; P<0.01), and right atrial reverse remodeling occurred (pPVR versus mPVR, 15.2±3.4 versus 13.8±3.6 cm2/m2; P<0.01). Larger preoperative RV outflow tract scar was associated with a smaller improvement in post-PVR RV/left ventricular ejection fraction. RV ejection fraction and peak oxygen uptake predicted mortality (P=0.03) over a median of 9.5 years of follow-up. CONCLUSIONS Significant right heart structural reverse remodeling takes place immediately after PVR, followed by a continuing process of further biological remodeling manifested by further reduction in RVESVi. PVR before RVESVi reaches 82 mL/m2 confers optimal chances of normalization of RV function.
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Affiliation(s)
- Ee Ling Heng
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Michael A Gatzoulis
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Anselm Uebing
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Babulal Sethia
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Hideki Uemura
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Gillian C Smith
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Gerhard-Paul Diller
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Karen P McCarthy
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Siew Yen Ho
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Wei Li
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Piers Wright
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Veronica Spadotto
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Philip J Kilner
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Paul Oldershaw
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Dudley J Pennell
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Darryl F Shore
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.)
| | - Sonya V Babu-Narayan
- From Adult Congenital Heart Disease Centre, (E.L.H., M.A.G., A.U.., B.S., H.U., W.L., V.S., P.O., D.F.S., S.V.B.-N.), Cardiac Morphology Unit (K.P.M., S.Y.H.), and Non-Invasive Cardiology Department (P.W.), Royal Brompton Hospital, London, United Kingdom; National Institute for Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College London, United Kingdom (E.L.H., M.A.G., G.C.S., P.J.K., D.J.P., D.F.S., S.V.B.-N.); Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital of Münster, Germany (G.-P.D.); and Department of Thoracic and Cardiovascular Sciences, University of Padua, Italy (V.S.).
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