Left Ventricular Dysfunction Following Repair of Ventricular Septal Defects in Infants

Left ventricular systolic dysfunction (LVSD) is frequently observed following repair of ventricular septal defects (VSD), although little is known about its incidence, time course, or risk factors. Among infants undergoing VSD repair, for postoperative LVSD, we sought to determine (1) incidence, (2) predictors, and (3) time to resolution. We queried our institution's surgical database for infants who underwent repair of isolated VSDs from November 2001 through January 2019. The primary outcome was postoperative LVSD, which was defined as a shortening fraction (SF) of <26% by M-mode. Postoperative echocardiograms were reviewed, and measurements were made using standard methods. Receiver operating characteristic analysis was generated to determine the preoperative left ventricular internal dimension (LVIDd) z-score most predictive of LVSD. Multivariable analysis was conducted to determine associations with LVSD; covariates in the model were weight percentile, genetic syndrome, preoperative diuretic, VSD type, and preoperative LVIDd z-score. Of the 164 patients who met inclusion criteria, 62 (38%) had postoperative LVSD. Fifty-eight (94%) of patients had resolution of LVSD within 9 months of surgery. Preoperative LVIDd z-score of >3.1 was associated with both an increased incidence of postoperative LVSD and prolonged time to resolution. Multivariable logistic regression analysis showed only preoperative LVIDd z-score was independently associated with postoperative LVSD. LVSD following VSD closure is common, but nearly all cases resolve by 9 months postoperatively. Elevated LVIDd prior to surgery is associated with postoperative LVSD. These data suggest VSD closure should be considered prior to the development of significant left ventricular dilation.

Effect of Preoperative Volume Overload on Left Ventricular Function Recovery After Ventricular Septal Defect Repair

Significant left-to-right shunt across a ventricular septal defect (VSD) may lead to left ventricle (LV) volume overload and dilation. The acute loss of LV preload after repair of VSD may contribute to postoperative LV systolic dysfunction. The primary aim of the study is to assess the effect of presence of preoperative LV dilation on LV systolic function recovery after VSD repair. We evaluated the LV systolic function by measuring LV longitudinal strain and ejection fraction (EF) before surgery (time point 1) and at 5 time points after VSD repair (time point 2: 0 to 2 weeks, time point 3: 2 to 6 weeks, time point 4: 6 weeks to 4 months, time point 5: 4 to 12 months, and time point 6: >12 months). A total of 120 patients were included in the study cohort. A total of 84 patients (70%) had LV dilation (group 1) and 36 patients (30%) had normal LV size on preoperative echocardiogram (group 2). Median age (interquartile range 25% to 75%) at surgery was 5.5 months (4 to 10) and 7 months (5 to 44.5) in groups 1 and 2 respectively (p = 0.03). Mean LV EF and strain were not significantly different among the 2 groups at time point 1. At time point 2, both mean EF and strain were significantly lower in group 1 compared with group 2 (p <0.05). At time point 3, mean EF was not significantly different among the two groups, while mean LV strain was significantly lower in group 1 (p = 0.044). At time points 4, 5 and 6, mean EF and strain were not significantly different between the two groups. In conclusion, presence of preoperative LV dilation is associated with a more pronounced LV systolic dysfunction in the early postoperative period only. The LV systolic function recovers back to the baseline after the first year following the repair. These are very reassuring prognostic findings.

Cardiac Function and Serum Biomarkers throughout Staged Fontan Palliation: A Prospective Observational Study

Fontan patients undergo multiple cardiothoracic surgeries in childhood. Following these procedures, ventricular function is temporarily decreased, and recovers over months. This is presumably related to cardiopulmonary bypass, but this is incompletely understood. Throughout the Fontan palliation, cardiac function is also affected by volume unloading. We aimed to gain insight into the biological processes related to impaired ventricular function and recovery following Fontan palliations using a panel of biomarkers. Furthermore, we described changes in ventricular function across the Fontan palliation due to volume unloading. We performed a prospective multicenter observational study in patients undergoing partial (PCPC) or total cavo-pulmonary connection (TCPC). Patients underwent assessment-including echocardiography and blood sampling-before surgery (T1), at first follow-up (T2), and 1 year after their procedures (T3). Blood samples were analyzed using a biomarker panel (OLINK CVD-III). Ninety-two biomarkers were expressed as principal components (PC) to limit multiple statistical testing. We included 32 PCPC patients aged 7.2 [5.3-10.3] months, and 28 TCPC patients aged 2.7 [2.2-3.8] years. The single ventricular longitudinal strain (SV GLS) temporarily decreased for PCPC patients at T2 (-15.1 ± 5.6 (T1) to -13.5 ± 5.2 (T2) to -17.3 ± 4.5 (T3), p < 0.047 for all differences), but not following TCPC. The serum biomarkers were expressed as 4 PCs. PC1, including biomarkers of cell-cell adhesion, was not related to any patient characteristic. PC2, including biomarkers of superoxide anion regulation, increased at T2. PC3, including biomarkers of cardiovascular development, related to the stage of Fontan palliation. PC4 was of uncertain biological or clinical significance. No PC was found that related to ventricular performance. The SV GLS was temporarily diminished following PCPC, but not following TCPC. Several biomarkers were related to post-operative stress and adaptation to the PCPC or TCPC circulation, but none were related to the outcome.

Functional Echocardiographic and Serum Biomarker Changes Following Surgical and Percutaneous Atrial Septal Defect Closure in Children

Background

Ventricular performance is temporarily reduced following surgical atrial septal defect closure. Cardiopulmonary bypass and changes in loading conditions are considered important factors, but this phenomenon is incompletely understood. We aim to characterize biventricular performance following surgical and percutaneous atrial septal defect closure and to relate biomarkers to ventricular performance following intervention.

Methods and Results

In this multicenter prospective study, children scheduled for surgical or percutaneous atrial septal defect closure were included. Subjects were assessed preoperatively, in the second week postintervention (at 2‐weeks follow‐up), and 1‐year postintervention (1‐year follow‐up). At each time point, an echocardiographic study and a panel of biomarkers were obtained. Sixty‐three patients (median age, 4.1 [interquartile range, 3.1–6.1] years) were included. Forty‐three patients underwent surgery. At 2‐weeks follow‐up, right ventricular global longitudinal strain was decreased for the surgical, but not the percutaneous, group (−17.6±4.1 versus −27.1±3.4; P<0.001). A smaller decrease was noted for left ventricular global longitudinal strain at 2‐weeks follow‐up for the surgical group (surgical versus percutaneous, −18.6±3.2 versus −20.2±2.4; P=0.040). At 1‐year follow‐up, left ventricular performance returned to baseline, whereas right ventricular performance improved, but did not reach preintervention levels. Eight biomarkers relating to cardiovascular and immunological processes differed across study time points. Of these biomarkers, only NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) correlated with less favorable left ventricular global longitudinal strain at 2‐weeks follow‐up.

Conclusions

Right, and to a lesser degree left, ventricular performance was reduced early after surgical atrial septal defect closure. Right ventricular performance at 1‐year follow‐up remained below baseline levels. Several biomarkers showed a pattern over time similar to ventricular performance. These biomarkers may provide insight into the processes that affect ventricular function.

Registration

URL: https://www.trialregister.nl/; Unique identifier: NL5129

Left Ventricular Systolic Impairment after Pediatric Cardiac Surgery Assessed by STE Analysis

Background: Speckle-tracking echocardiography (STE) has gained increasing value in the evaluation of congenital heart diseases (CHD); however, its use in pediatric cardiac surgery is limited. Aim: To evaluate left ventricular (LV) systolic impairment after biventricular pediatric cardiac surgery by STE strain (ε) analysis. Methods: We prospectively enrolled 117 children undergoing cardiac surgery for CHD. Echocardiography was performed at four different times: pre-operatively, 12–36 h (Time 1), 3–5 days (Time 2), and 6–8 days (Time 3). Images were obtained in the 4-2-and 3 apical chamber’s views to derive LV global and regional (basal/mid/apical) ε values. Results: At different postoperative times, we performed 320 examinations in 117 children (mean age: 2.4 ± 3.9, range: 0–16 years); 117 age-matched healthy children served as controls. All global, basal, and mid LVε values decreased after surgery; the lowest values being at Time 1 (p < 0.0001), which increased thereafter. At discharge, all global, basal, and mid LVε values remained lower than in pre-operative and healthy children (p < 0.05). Instead, apical segments (lowest at baseline) increased after surgery (p < 0.0001) but remained lower compared to controls. LV ejection fraction (LVEF) decreased at Time 1 (p = 0.0004) but promptly recovered to Time 2 and normalized at Time 3. Conclusions: STE ε analysis revealed a significant LV systolic impairment after surgery with amelioration thereafter but incomplete normalization at discharge. Base-apex differences emerged with apical segments that, contrary to all the other regions, showed relative hypercontractility after surgery. The slower recovery of LVε values compared to LVEF suggests that STE ε analysis may be more accurate for the follow-up of mild LV post-surgical impairment.

Procedural and short-term outcomes of transcatheter closure of ventricular septal defect using lifetech multifunctional occluder: initial experience

The Lifetech Multifunctional occluder is a versatile device with an improved delivery and flexibility that reduces the risk of atrioventricular block. This is a retrospective, descriptive, pilot study done in 25 patients who underwent transcatheter closure of ventricular septal defect using Lifetech Multifunctional occluder from February 2017 to January 2018.The average age was 9.32 ± 7.20 years, with a range from 1 to 32 years. Procedural success was 100% with no case needing a change of device size. Closure rate on follow up was at 42% (10/24), 52% (12/23), and 81% (17/21) at 1 day, 1 month, and 6 months, respectively. At 6-month follow up, pre-procedure tricuspid regurgitation disappeared by 38%. However, the incidence of new onset tricuspid regurgitation to trace was 16% (2) and mild 8% (1). Pre-procedure mild aortic regurgitation remained the same status throughout the 6-month follow up. Closure of the defect did not improve or worsen the aortic regurgitation. Post-transcatheter closure of ventricular septal defect with mild infundibular hypertrophy, the 1-year-old patient had resolution of the infundibular hypertrophy after 6 months but our 9-year-old patient had persistence of the mild infundibular hypertrophy even after 6 months. One patient (4%) developed transient widened QRS complexes post-transcatheter closure that resolved after 1 month. In total, 92% of the patients had no periprocedural complications. While one patient each had an inadvertent urinary bladder puncture and device embolisation.Our retrospective review of the procedural and short-term outcomes of transcatheter closure of ventricular septal defect sizes 2-10 mm, using the Lifetech Multifunctional occluder, appears to be safe and effective. However, long-term follow up is warranted.

Myocardial performance after coronary re-implantation in pediatric patients assessed with conventional echocardiographic and 2D-speckle tracking analysis: a case-control study

Introduction

reduced exercise capacity, coronary artery abnormalities and reversible myocardial ischemia have been demonstrated after arterial switch operation (ASO) and coronary reimplantation. Despite this, indices of systolic function, assessed by standard and Doppler echocardiography, are within the normal range. The aim of this study was to highlight the long-term changes in myocardial function following coronary reimplantation using Doppler and speckle-tracking imaging (STI) echocardiography.

Methods

this observational case control study included 36 patients and 20 gender and age-matched healthy controls. A group study was performed using patients who were followed for at least 6 months after the operation and who visited the pediatric cardiology outpatient between October 2015 and May 2016. Systolic and diastolic parameters, left ventricle (LV) and right ventricle (RV) myocardial performance were assessed in each group.

Results

the LV global peak strain parameters revealed a significant decrease in the longitudinal and circumferential strain components. The LV global longitudinal strain (GLS) values were lower in both groups of operated patients than controls (-19.9 ± 2.2% (group 1) versus -20.9 ± 1.6% (group 2) versus -22.9 ± 2.3% (group 3), p<0.001). The patients with coronary reimplantation had the lowest values. The LV global circumferential strain was also decreased in the group 1 patients as compared with the 2 other groups (-16.6 ± 4.1% (group 1) versus -19.4 ± 3.9% (group 2) versus -19.8 ± 4.0% (group 3), p<0.001).

Conclusion

although global LV function, assessed with conventional echocardiographic parameters, was normal, the 2D-STI analysis showed slight but significant decrease in the global and segmental longitudinal and circumferential LV strain during the long-term follow-up after coronary arteries reimplantation.

Echocardiography for the Assessment of Pulmonary Hypertension and Congenital Heart Disease in the Young

While invasive assessment of hemodynamics and testing of acute vasoreactivity in the catheterization laboratory is the gold standard for diagnosing pulmonary hypertension (PH) and pulmonary vascular disease (PVD) in children, transthoracic echocardiography (TTE) serves as the initial diagnostic tool. International guidelines suggest several key echocardiographic variables and indices for the screening studies when PH is suspected. However, due to the complex anatomy and special physiological considerations, these may not apply to patients with congenital heart disease (CHD). Misinterpretation of TTE variables can lead to delayed diagnosis and therapy, with fatal consequences, or–on the other hand-unnecessary invasive diagnostic procedures that have relevant risks, especially in the pediatric age group. We herein provide an overview of the echocardiographic workup of children and adolescents with PH with a special focus on children with CHD, such as ventricular/atrial septal defects, tetralogy of Fallot or univentricular physiology. In addition, we address the use of echocardiography as a tool to assess eligibility for exercise and sports, a major determinant of quality of life and outcome in patients with PH associated with CHD.

Left and Right Ventricular Impairment Shortly After Correction of Tetralogy of Fallot

Surgical repair of Tetralogy of Fallot (ToF) is usually performed in the first months of life with low early postoperative mortality. During long-term follow-up, however, both right (RV) and left ventricular (LV) performances may deteriorate. Tissue Doppler imaging (TDI) and speckle tracking echocardiography (ST) can unmask a diminished RV and LV performance. The objective of the current study was to assess the cardiac performance before and shortly after corrective surgery in ToF patients using conventional, TDI and ST echocardiographic techniques. Thirty-six ToF patients after surgery were included. Transthoracic echocardiography including TDI and ST techniques was performed preoperatively and at hospital discharge after surgery (10 days to 4 weeks after surgery). Median age at surgery was 7.5 months [5.5-10.9]. Regarding the LV systolic function there was a significant decrease in interventricular septum (IVS) S' at discharge as compared to preoperatively (pre IVS S' = 5.4 ± 1.4; post IVS S' = 3.9 ± 1.2; p < 0.001) and in global longitudinal peak strain (GLS) (pre = - 18.3 ± 3.4; post = - 14.2 ± 4.1; p = 0.003); but not in the fractional shortening (FS). Both conventional and TDI parameters showed a decrease in diastolic function at discharge. Tricuspid Annular Plane Systolic Excursion and RV S' were significantly lower before discharge. When assessing the RV diastolic performance, only the TDI demonstrated a RV impairment. There was a negative correlation between age at surgery and postoperative LV GLS (R = - 0.41, p = 0.031). There seems to be an impairment in left and right ventricle performance at discharge after ToF corrective surgery compared to preoperatively. This is better determined with TDI and ST strain imaging than with conventional echocardiography.

Long-term follow-up after ventricular septal defect repair in children: cardiac autonomic control, cardiac function and exercise capacity

OBJECTIVES

Survival after surgical repair of a ventricular septal defect (VSD) is good, but, as in almost all congenital heart diseases, late complications are frequent in adulthood. The exact mechanisms, timing and who is at risk are not fully understood. Altered cardiac autonomic nervous system (ANS) activity might play a role in these long-term sequelae. The aim of this study was to extensively evaluate children late after VSD repair including their cardiac ANS activity, cardiac function and exercise capacity.

METHODS

Thirty-three patients after surgical VSD repair and 66 healthy age-matched controls underwent 24-h monitoring of ANS control and cardiac output using impedance cardiography, detailed echocardiography and cardiopulmonary exercise testing.

RESULTS

Ambulatory cardiac ANS control was not different between the patients and the controls. Right ventricular function, exercise capacity and ambulatory cardiac output were decreased in patients compared with the controls. No relationships were found between cardiac ANS activity and cardiac function.

CONCLUSIONS

Long (average time after repair was 9.9 years) after successful surgical correction of a VSD, cardiac ANS control is not different from the controls. Right ventricular function and exercise capacity are impaired in VSD patients. Post-surgical outcome in these patients may be less benign than presently assumed; therefore, follow-up should be continued into adulthood to detect adverse outcomes in a timely fashion.

Left ventricular rotation and torsion in neonates and infants younger than three months with symptomatic ventricular septal defect: Acute effects from open heart surgery

PURPOSE

We evaluated ventricular rotation, torsion, and strain changes in infants using preoperative and postoperative M-mode echocardiography after early surgery for symptomatic ventricular septal defects (VSD).

METHODS

Thirty-five patients with VSD underwent vector velocity imaging echocardiography before and after open heart surgery. Their rotational variables were compared with 18 controls.

RESULTS

All the patients (19 boys and 16 girls; median age: 44.4 days; range: 13-84 days) showed normal septal motion preoperatively; however, septal motion changed into flat septum or paradoxical septal motion after surgery. Left ventricular end-diastolic internal dimension and fractional shortening significantly decreased after surgery (P = .001 and P = .000). Patients showed significant postoperative reduction of peak systolic apical rotation and maximal torsion (P = .010 and P = .000). Peak systolic basal rotation decreased after surgery but it was not significantly (P = .106). No significant differences were found in longitudinal and circumferential systolic strains between patients and controls.

CONCLUSION

Abnormal motion of the ventricular septum was confirmed by postoperative M-mode echocardiography. Decreased rotation/torsion variables may reflect postoperative changes of ventricular loading conditions. Because systolic strain was preserved, postoperative echocardiographic results should not be interpreted as abnormal or decreased ventricular function.

Alterations in ventricular pumping in patients with atrial septal defect at rest, during dobutamine stress and after defect closure

BACKGROUND

Regional ventricular pumping mechanisms in patients with volume-loaded right ventricles (RV) are altered, but the cause is unknown. The aim was to determine whether these changes in ventricular pumping mechanisms are influenced by the RV dilatation itself or the aetiology behind it.

METHODS

Seventeen patients with atrial septal defects (ASD) and 10 healthy controls underwent cardiovascular magnetic resonance (CMR) at rest and during dobutamine/atropine stress. Sixteen patients underwent transcutaneous ASD closure. Follow-up CMR at rest was performed the following day. Thirty patients with RV overload due to pulmonary regurgitation (PR) underwent CMR at rest. Cine images were used to measure left ventricular (LV) and RV volumes as well as septal, longitudinal and lateral contributions to LV and RV stroke volume (SV).

RESULTS

At rest, septal contribution to LVSV was lower in ASD patients than controls (-1% versus 7%, P<0·05), but there was no difference in longitudinal or lateral contribution to SV. Patients with PR had lower longitudinal contribution to RV with increased lateral and septal contribution. During dobutamine stress, longitudinal contribution to LV and RVSV decreased and lateral contribution increased for ASD patients and controls. The day after ASD closure, septal contribution to LVSV was 6%, longitudinal contribution had increased for RVSV (P<0·05) and decreased for LVSV (P<0·01).

CONCLUSION

Pumping mechanisms in patients with RV volume overload depend on the aetiology for the RV dilation and not the size of the RV.

Ventricular mechanics after repair of subarterial and perimembranous VSDs

BACKGROUND

Emerging data suggest impaired biventricular function in adults late after repair of ventricular septal defect (VSD). We assessed and compared right (RV) and left ventricular (LV) mechanics in adolescents and adults after surgical closure of doubly committed subarterial and perimembranous VSDs.

METHODS

A total of 75 subjects were studied: 29 patients after subarterial VSD repair (group I), 17 patients after perimembranous VSD repair (group II) and 29 age-matched controls (group III). RV and LV mechanics were assessed using tissue Doppler and speckle-tracking echocardiography, while RV outflow systolic function was quantified by systolic excursion and fractional shortening (FS).

RESULTS

Compared with group III, groups I and II had significantly reduced tricuspid annular systolic and diastolic velocities, isovolumic myocardial acceleration, RV global longitudinal systolic and diastolic deformation parameters and RV outflow systolic excursion (all P < .05). Group I, but not II, had reduced RV outflow FS (P = .008) and the lowest global LV longitudinal systolic strain (P = .008) and systolic strain rate (P = .014). In group I, postoperative aortic regurgitation was associated with lower LV longitudinal systolic strain (P = .009) and early diastolic strain rate (P = .002), while right bundle branch block was associated with lower RV systolic strain rate (P = .048). As a group, RV outflow excursion (P < .001) and FS (P = .001) were correlated with LV global systolic strain.

CONCLUSION

Adolescents and adults late after repair of subarterial and perimembranous VSDs show impairment of RV systolic and diastolic myocardial deformation. The RV outflow function and LV systolic deformation appear to be worse after repair of subarterial defects.

Reference Ranges of Left Ventricular Strain Measures by Two-Dimensional Speckle-Tracking Echocardiography in Children: A Systematic Review and Meta-Analysis

BACKGROUND

Establishment of the range of reference values and associated variations of two-dimensional speckle-tracking echocardiography (2DSTE)-derived left ventricular (LV) strain is a prerequisite for its routine clinical adoption in pediatrics. The aims of this study were to perform a meta-analysis of normal ranges of LV global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) measurements derived by 2DSTE in children and to identify confounding factors that may contribute to variance in reported measures.

METHODS

A systematic review was launched in MEDLINE, Embase, Scopus, the Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library. Search hedges were created to cover the concepts of pediatrics, STE, and left-heart ventricle. Two investigators independently identified and included studies if they reported 2DSTE-derived LV GLS, GCS, or GRS. The weighted mean was estimated by using random effects models with 95% CIs, heterogeneity was assessed using the Cochran Q statistic and the inconsistency index (I(2)), and publication bias was evaluated using the Egger test. Effects of demographic (age), clinical, and vendor variables were assessed in a metaregression.

RESULTS

The search identified 2,325 children from 43 data sets. The reported normal mean values of GLS among the studies varied from -16.7% to -23.6% (mean, -20.2%; 95% CI, -19.5% to -20.8%), GCS varied from -12.9% to -31.4% (mean, -22.3%; 95% CI, -19.9% to -24.6%), and GRS varied from 33.9% to 54.5% (mean, 45.2%; 95% CI, 38.3% to 51.7%). Twenty-six studies reported longitudinal strain only from the apical four-chamber view, with a mean of -20.4% (95% CI, -19.8% to -21.7%). Twenty-three studies reported circumferential strain (mean, -20.3%; 95% CI, -19.4% to -21.2%) and radial strain (mean, 46.7%; 95% CI, 42.3% to 51.1%) from the short-axis view at the midventricular level. A significant apex-to-base segmental longitudinal strain gradient (P < .01) was observed in the LV free wall. There was significant between-study heterogeneity and inconsistency (I(2) > 94% and P < .001 for each strain measure), which was not explained by age, gender, body surface area, blood pressure, heart rate, frame rate, frame rate/heart rate ratio, tissue-tracking methodology, location of reported strain value along the strain curve, ultrasound equipment, or software. The metaregression showed that these effects were not significant determinants of variations among normal ranges of strain values. There was no evidence of publication bias (P = .40).

CONCLUSIONS

This study defines reference values of 2DSTE-derived LV strain in children on the basis of a meta-analysis. In healthy children, mean LV GLS was -20.2% (95% CI, -19.5% to -20.8%), mean GCS was -22.3% (95% CI, -19.9% to -24.6%), and mean GRS was 45.2% (95% CI, 38.3% to 51.7%). LV segmental longitudinal strain has a stable apex-to-base gradient that is preserved throughout maturation. Although variations among different reference ranges in this meta-analysis were not dependent on differences in demographic, clinical, or vendor parameters, age- and vendor-specific referenced ranges were established as well.

Does surgically induced right bundle branch block really effect ventricular function in children after ventricular septal defect closure?

In this prospective study, we aimed to assess left and right ventricular function in terms of the presence of right bundle branch block (RBBB) in the cases with repaired ventricular septal defect (VSD). Fifty-three patients who had VSD surgery at least 1-year preceding admission and 52 healthy controls were enrolled into the study. All the participants underwent electrocardiographic and echocardiographic examination. The cases with RBBB were determined. The conventional and tissue Doppler echocardiographic measurements of the patients with and without RBBB were compared with each other and healthy controls. Twenty-eight of VSD repair groups were male and 25 were female. Control group consisted of 30 males and 22 females. The mean age of the study and control groups was 7.5 ± 5.0 and 6.9 ± 4.3 years, respectively. RBBB was detected in 20 of 53 (37.7 %) operated patients. The only significant difference between the cases with and without RBBB was decreased right ventricular fractional area change (%) in the former group (33 ± 7 vs. 39 ± 5 p < 0.05). When compared to controls, operated group had statistically lower [corrected] tricuspid annular plane systolic excursion (p < 0.05), lower systolic, early diastolic, and late diastolic myocardial velocities, higher left and right ventricular myocardial performance indices, irrespective of the presence of RBBB. The ratios of mitral or tricuspid inflow to left or right ventricular myocardial in early diastolic velocities measured from lateral annular levels were increased in operated group (all p values <0.05). In conclusion, RBBB in the cases with surgical VSD repair might be associated with right ventricular dysfunction. Biventricular systolic and diastolic dysfunction may develop following VSD repair irrespective of the presence of RBBB. Tissue Doppler-derived myocardial performance indices are useful in detection of those subclinical dysfunctions.

Ventricular performance after surgery for a congenital heart defect as assessed using advanced echocardiography: from doppler flow to 3D echocardiography and speckle-tracking strain imaging

A varying degree of impairment of ventricular performance is observed over the long-term after surgery for a congenital heart defect (CHD). Impaired ventricular performance has been shown to be of prognostic value for increased risk of cardiovascular events in adult CHD patients. This emphasizes the importance of delineating the timing and cause of this postoperative impairment. Impairment of ventricular performance could develop over time as a consequence of residua, sequelae and complications of the CHD or surgical procedure. Yet, impaired ventricular performance has also been observed immediately after surgery and can persist and/or worsen over time. This postoperative impairment of ventricular performance is the focus of this review. This article provides an overview of echocardiographic techniques currently used to assess ventricular performance. Furthermore, we review current literature describing ventricular performance, as assessed using echocardiography, after correction of a CHD. In general, a decrease in ventricular performance is observed directly after surgery for CHD’s. Subsequent follow-up of ventricular performance is characterized by a varying degree of postoperative recovery. A consistent observation is the persistent impairment of right-ventricular performance after repair in several different subgroups of CHD patients ranging from ventricular septal defect repair to surgery for Tetralogy of Fallot.