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Elizabeth Kaiser A, Husnain MA, Fakhare Alam L, Kumar Murugan S, Kumar R. Management of Fallot's Uncorrected Tetralogy in Adulthood: A Narrative Review. Cureus 2024; 16:e67063. [PMID: 39286683 PMCID: PMC11403652 DOI: 10.7759/cureus.67063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2024] [Indexed: 09/19/2024] Open
Abstract
The majority of cyanotic congenital cardiac defects are caused by the tetralogy of Fallot. Some symptoms include a biventricular connection of the aortic root, right ventricular hypertrophy, blockage of the right ventricular outflow tract, and a ventricular septal defect. Our understanding of tetralogy of Fallot (TOF) has significantly advanced since it was first described in 1888, and early diagnosis has led to improved surgical management and increased life expectancy. Adults with unrepaired and repaired TOF present with a range of late complications, including heart failure, the need for re-interventions, and late arrhythmias. Right ventricular (RV) failure, often caused by chronic pulmonary regurgitation, is a significant cause of heart failure in patients with TOF. Current treatment options are limited, and mainstay surgical procedures such as pulmonary-valve replacement (PVR), trans-annular repair (TAR), or infundibular widening repair have not shown a significant reduction in preventing right ventricular (RV) failure or death. Here, we explain the mechanisms of RV failure in ToF, chronic pulmonary regurgitation, heart failure, and secondary polycythemia. HF management in untreated adults is discussed. The progression of the disease, as well as complications, are also discussed. The treatment plan and the need to investigate the best management approach for this unsolved problem are included. This review aims to fill the knowledge gaps and supply valuable information regarding mechanisms of RV failure, chronic pulmonary regurgitation, and secondary polycythemia. To summarize, a new combat strategy must be found to battle RVF, and a more profound vision of these mechanisms is required. If it is not corrected, it will be one of the future research lines that will contribute to designing more efficacious treatment techniques for adults with TOF.
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Affiliation(s)
| | | | | | - Siva Kumar Murugan
- Department of Medicine, Meenakshi Medical College and Research Institute, Kanchipuram, IND
| | - Rajanikant Kumar
- Cardiothoracic Surgery, Medanta Superspeciality Hospital, Patna, IND
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Crucean A, Spicer DE, Tretter JT, Mohun TJ, Anderson RH. Revisiting the anatomy of the right ventricle in the light of knowledge of its development. J Anat 2024; 244:297-311. [PMID: 37814425 PMCID: PMC10780169 DOI: 10.1111/joa.13960] [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: 03/04/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 10/11/2023] Open
Abstract
Controversies continue regarding several aspects of the anatomy of the morphologically right ventricle. There is disagreement as to whether the ventricle should be assessed in bipartite or tripartite fashion, and the number of leaflets to be found in the tricuspid valve. In particular, there is no agreement as to whether a muscular outlet septum is present in the normally constructed heart, nor how many septal components are to be found during normal development. Resolving these issues is of potential significance to those investigating and treating children with congenitally malformed hearts. With all these issues in mind, we have revisited our own experience in investigating the development and morphology of the normal right ventricle. To assess development, we have examined a large number of datasets, prepared by both standard and episcopic microscopy, from human and murine embryos. In terms of gross anatomy, we have compared dissections of normal autopsied hearts with virtual dissections of datasets prepared using computed tomography. Our developmental and postnatal studies, taken together, confirm that the ventricle is best assessed in tripartite fashion, with the three parts representing its inlet, apical trabecular, and outlet components. The ventricular septum, however, has only muscular and membranous components. The muscular part incorporates a small component derived from the muscularised fused proximal outflow cushions, but this part cannot be distinguished from the much larger part that is incorporated within the free-standing muscular infundibular sleeve. We confirm that the tricuspid valve itself has three components, which are located inferiorly, septally, and antero-superiorly.
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Affiliation(s)
- Adrian Crucean
- Department of Paediatric Cardiac SurgeryBirmingham Women's and Children's HospitalBirminghamUK
| | - Diane E. Spicer
- Congenital Heart CenterAll Children's HospitalSt PetersbergFloridaUSA
| | - Justin T. Tretter
- Department of Pediatric Cardiology, Cleveland Clinic Children's, and the Heart, Vascular, and Thoracic InstituteCleveland ClinicClevelandOhioUSA
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Carrasco M, Cabrito TMS, Montalbano MJ, Hołda MK, Walocha J, Tubbs RS, Loukas M. Cardiac ventricular false tendons: A meta-analysis. Clin Anat 2024; 37:114-129. [PMID: 37819143 DOI: 10.1002/ca.24116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 09/08/2023] [Indexed: 10/13/2023]
Abstract
Ventricular false tendons are fibromuscular structures that travel across the ventricular cavity. Left ventricular false tendons (LVFTs) have been examined through gross dissection and echocardiography. This study aimed to comprehensively evaluate the prevalence, morphology, and clinical importance of ventricular false tendons using a systematic review. In multiple studies, these structures have had a wide reported prevalence ranging from less than 1% to 100% of cases. This meta-analysis found the overall pooled prevalence of LVFTs to be 30.2%. Subgroup analysis indicated the prevalence to be 55.1% in cadaveric studies and 24.5% in living patients predominantly studied by echocardiography. Morphologically, left and right ventricular false tendons have been classified into several types based on their location and attachments. Studies have demonstrated false tendons have important clinical implications involving innocent murmurs, premature ventricular contractions, early repolarization, and impairment of systolic and diastolic function. Despite these potential complications, there is evidence demonstrating that the presence of false tendons can lead to positive clinical outcomes.
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Affiliation(s)
- Mark Carrasco
- Department of Family Medicine, HealthQuest, Rhinebeck, New York, USA
| | | | | | - Mateusz K Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
- Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - Jerzy Walocha
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - R Shane Tubbs
- Department of Anatomical Sciences, St. George's University, West Indies
- Department of Neurosurgery, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA
| | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, West Indies
- Department of Anatomy, University of Warmia and Mazury, Olsztyn, Poland
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4
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Ali H, Lupo P, Foresti S, De Ambroggi G, Anderson RH, De Lucia C, Turturiello D, Paganini EM, Bessi R, Contrafatto I, Farghaly AAA, Cristiano E, Cappato R. Catheter-induced right bundle branch block: Practical implications for the cardiac electrophysiologist. J Cardiovasc Electrophysiol 2023; 34:2316-2329. [PMID: 37655997 DOI: 10.1111/jce.16050] [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: 05/17/2023] [Revised: 06/23/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023]
Abstract
The right bundle branch (RBB), due to its endocardial course, is susceptible to traumatic block caused by "bumping" during right-heart catheterization. In the era of cardiac electrophysiology, catheter-induced RBB block (CI-RBBB) has become a common phenomenon observed during electrophysiological studies and catheter ablation procedures. While typically transient, it may persist for the entire procedure time. Compared to pre-existing RBBB, the transient nature of CI-RBBB allows for comparative analysis relative to the baseline rhythm. Furthermore, unlike functional RBBB, it occurs at similar heart rates, making the comparison of conduction intervals more reliable. While CI-RBBB can provide valuable diagnostic information in various conditions, it is often overlooked by cardiac electrophysiologists. Though it is usually a benign and self-limiting conduction defect, it may occasionally lead to diagnostic difficulties, pitfalls, or undesired consequences. Avoidance of CI-RBBB is advised in the presence of baseline complete left bundle branch block and when approaching arrhythmic substrates linked to the right His-Purkinje-System, such as fasciculo-ventricular pathways, bundle branch reentry, and right-Purkinje focal ventricular arrhythmias. This article aims to provide a comprehensive practical review of the electrophysiological phenomena related to CI-RBBB and its impact on the intrinsic conduction system and various arrhythmic substrates.
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Affiliation(s)
- Hussam Ali
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Pierpaolo Lupo
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Sara Foresti
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Guido De Ambroggi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, UK
| | - Carmine De Lucia
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Dario Turturiello
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Edoardo Maria Paganini
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Bessi
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Igino Contrafatto
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Cardiac Electrophysiology, Salus Hospital, Reggio Emilia, Italy
| | - Ahmad Abdelrady Abdelsalam Farghaly
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- Cardiovascular Department, Assiut University, Assiut, Egypt
| | - Ernesto Cristiano
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Riccardo Cappato
- Arrhythmia & Electrophysiology Centre, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
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Lis M, Krawczyk-Ożóg A, Hołda J, Tyrak K, Dudkiewicz D, Yakovliev A, Strona M, Bolechała F, Jakiel R, Jakiel M, Hołda MK. Pulmonary valve morphometry revisited: Clinical implications for valvular and supravalvular interventions. Clin Anat 2023; 36:234-241. [PMID: 36193818 DOI: 10.1002/ca.23959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/06/2022]
Abstract
In this cadaver-based study, we aimed to present a novel approach to pulmonary valve (PV) anatomy, morphometry, and geometry to offer comprehensive information on PV structure. The 182 autopsied human hearts were investigated morphometrically. The largest PV area was seen for the coaptation center plane, followed by basal ring and the tubular plane (626.7 ± 191.7 mm2 vs. 433.9 ± 133.6 mm2 vs. 290.0 ± 110.1 mm2 , p < 0.001). In all leaflets, fenestrations are noted and occur in 12.5% of PVs. Only in 31.3% of PVs, the coaptation center is located in close vicinity of the PV geometric center. Similar-sized sinuses were found in 35.7% of hearts, in the remaining cases, significant heterogeneity was seen in size. The mean sinus depth was: left anterior 15.59 ± 2.91 mm, posterior: 16.04 ± 2.82 mm and right anterior sinus: 16.21 ± 2.81 mm and the mean sinus height: left anterior 15.24 ± 3.10 mm, posterior: 19.12 ± 3.79 mm and right anterior sinus: 18.59 ± 4.03 mm. For males, the mean pulmonary root perimeters and areas were significantly larger than those for females. Multiple forward stepwise regression model showed that anthropometric variables might predict the coaptation center plane (sex, age, and heart weight; R2 = 33.8%), tubular plane (sex, age, and BSA; R2 = 20.5%) and basal ring level area (heart weight and sex; R2 = 17.1%). In conclusion, the largest pulmonary root area is observed at the coaptation center plane, followed by the basal ring and tubular plane. The PV geometric center usually does not overlap valve coaptation center. Significant heterogeneity is observed in the size of sinuses and leaflets within and between valves. Anthropometric variables may be used to predict pulmonary root dimensions.
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Affiliation(s)
- Maciej Lis
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Agata Krawczyk-Ożóg
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Jakub Hołda
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Kamil Tyrak
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Damian Dudkiewicz
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Artem Yakovliev
- Institute of Nuclear Physics, Polish Academy of Sciences, Cracow, Poland
| | - Marcin Strona
- Department of Forensic Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Filip Bolechała
- Department of Forensic Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Rafał Jakiel
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Marcin Jakiel
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz K Hołda
- HEART - Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
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Ammari A, Mahmoudi R, Hmida B, Saouli R, Hedi Bedoui M. Deep-active-learning approach towards accurate right ventricular segmentation using a two-level uncertainty estimation. Comput Med Imaging Graph 2023; 104:102168. [PMID: 36640486 DOI: 10.1016/j.compmedimag.2022.102168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/23/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022]
Abstract
The Right Ventricle (RV) is currently recognised to be a significant and important prognostic factor for various pathologies. Its assessment is made possible using Magnetic Resonance Imaging (CMRI) short-axis slices. Yet, due to the challenging issues of this cavity, radiologists still perform its delineation manually, which is tedious, laborious, and time-consuming. Therefore, to automatically tackle the RV segmentation issues, Deep-Learning (DL) techniques seem to be the axis of the most recent promising approaches. Along with its potential at dealing with shape variations, DL techniques highly requires a large number of labelled images to avoid over-fitting. Subsequently, with the produced large amounts of data in the medical industry, preparing annotated datasets manually is still time-consuming, and requires high skills to be accomplished. To benefit from a significant number of labelled and unlabelled CMRI images, a Deep-Active-Learning (DAL) approach is proposed in this paper to segment the RV. Thus, three main steps are distinguished. First, a personalised labelled dataset is gathered and augmented to allow initial learning. Secondly, a U-Net based architecture is modified towards efficient initial accuracy. Finally, a two-level uncertainty estimation technique is settled to enable the selection of complementary unlabelled data. The proposed pipeline is enhanced with a customised postprocessing step, in which epistemic uncertainty and Dense Conditional Random Fields are used. The proposed approach is tested on 791 images gathered from 32 public patients and 1230 images of 50 custom subjects. The obtained results show an increased dice coefficient from 0.86 to 0.91 with a decreased Hausdorff distance from 7.55 to 7.45.
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Affiliation(s)
- Asma Ammari
- Medical Imaging Technology Laboratory, Faculty of Medicine, LTIM-LR12ES06, University of Monastir, 5019 Monastir, Tunisia; Laboratory of Intelligent Computing (LINFI), Department of Computer Science, Mohamed Khider University, BP 145 RP, Biskra 07000, Algeria; The National Engineering School ENIS, Sfax, Tunisia.
| | - Ramzi Mahmoudi
- Medical Imaging Technology Laboratory, Faculty of Medicine, LTIM-LR12ES06, University of Monastir, 5019 Monastir, Tunisia; Gaspard-Monge Computer-science Laboratory, Paris-Est University, Mixed Unit CNRS-UMLV-ESIEE UMR8049, BP99, ESIEE Paris City Descartes, 93162 Noisy Le Grand, France
| | - Badii Hmida
- Medical Imaging Technology Laboratory, Faculty of Medicine, LTIM-LR12ES06, University of Monastir, 5019 Monastir, Tunisia; Radiology Service, UR12SP40 CHU Fattouma Bourguiba, 5019 Monastir, Tunisia
| | - Rachida Saouli
- Laboratory of Intelligent Computing (LINFI), Department of Computer Science, Mohamed Khider University, BP 145 RP, Biskra 07000, Algeria
| | - Mohamed Hedi Bedoui
- Medical Imaging Technology Laboratory, Faculty of Medicine, LTIM-LR12ES06, University of Monastir, 5019 Monastir, Tunisia
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Varma PK, Jose RL, Krishna N, Srimurugan B, Valooran GJ, Jayant A. Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 1-anatomy, pathophysiology, and diagnosis). Indian J Thorac Cardiovasc Surg 2022; 38:45-57. [PMID: 34898875 PMCID: PMC8630124 DOI: 10.1007/s12055-021-01240-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 01/03/2023] Open
Abstract
Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s12055-021-01240-y.
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Affiliation(s)
- Praveen Kerala Varma
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Reshmi Liza Jose
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | - Balaji Srimurugan
- Divisions of Cardiovascular & Thoracic Surgery, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
| | | | - Aveek Jayant
- Divisions of Cardiac Anesthesiology, Amrita Institute of Medical Sciences, Amrita Viswa Vidyapeetham (Amrita University), Kochi, India
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MotMotshabi Chakane P. The right ventricle. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s3.2556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The healthy right ventricle (RV) has a thin-walled structure compared to the thick-walled left ventricle (LV). It has a complex shape that appears crescentic when viewed in cross section and triangular when viewed from the side.
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