1
|
Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [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: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
Collapse
Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| |
Collapse
|
2
|
Gonzalez de Alba C, Moghari MH, Browne LP, Friesen RM, Fonseca B, Malone LJ. Feasibility of gray-blood late gadolinium enhancement evaluation in young patients with congenital and acquired heart disease. Front Cardiovasc Med 2023; 10:1269412. [PMID: 37915741 PMCID: PMC10616296 DOI: 10.3389/fcvm.2023.1269412] [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] [Received: 07/30/2023] [Accepted: 09/26/2023] [Indexed: 11/03/2023] Open
Abstract
Background Late gadolinium enhancement (LGE) sequences have become common in pediatric cardiovascular magnetic resonance (CMR) to assess for myocardial fibrosis. Bright-blood late gadolinium enhancement (BB-LGE) by conventional phase-sensitive inversion recovery (PSIR) is commonly utilized, but similar inversion time (TI) value of fibrosis and left ventricular (LV) blood pool can make subendocardial areas difficult to assess. A gray-blood LGE (GB-LGE) technique has been described, targeting nulling of the LV blood pool and demonstrating improvement in ischemic scar detection over BB-LGE in adult patients. We sought to evaluate the feasibility of the GB-LGE technique in a young population with congenital and acquired heart disease and compare its ability to detect subendocardial scar to conventional BB-LGE. Methods Seventy-six consecutive patients referred for clinical CMR underwent both BB-LGE and GB-LGE on 1.5 T and 3 T scanners. Conventional PSIR sequences were obtained with TI to null the myocardium (BB-LGE) in short-axis and horizontal long-axis stacks. Same PSIR stacks were immediately repeated with TI to null the blood pool (GB-LGE). Both sequences were reviewed separately a week apart by two readers, blinded to the initial clinical interpretation. Studies were analyzed for overall image quality, confidence in scar detection, confidence in detection of LGE, LGE class, inter- and intra-observer agreement for the presence of scar, and intraclass correlation coefficient (ICC) for total scar burden. Results Overall confidence in myocardial scar detection by BB-LGE or GB-LGE as well as grading of image quality were not statistically different [(p = 1 and p = 1) and (p = 0.53, p = 0.18), respectively]. There was very good inter-observer agreement for the presence of scar on BB-LGE (K = 0.88, 95% CI 0.77-0.99) and GB-LGE (K = 0.84, 95% CI 0.7-0.96), as well as excellent intra-observer agreement for both readers (K = 0.93, 95% CI 0.87-0.99; and K = 0.81, 95% CI 0.69-0.95). Interclass correlation coefficient for total scar burden was excellent for BB-LGE (ICC = 0.98, 95% CI 0.96-0.99) and GB-LGE (ICC = 0.94, 95% CI 0.91-0.97). Conclusions The GB-LGE technique is feasible in the pediatric population with congenital and acquired heart disease. It can detect subendocardial/ischemic scar similar to conventional bright-blood PSIR sequences in the pediatric population.
Collapse
Affiliation(s)
- Cesar Gonzalez de Alba
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Mehdi H. Moghari
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Lorna P. Browne
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
| | - Richard M. Friesen
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - Brian Fonseca
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, United States
| | - LaDonna J. Malone
- Department of Radiology, University of Colorado, Aurora, CO, United States
- Department of Radiology, Children’s Hospital Colorado, Aurora, CO, United States
| |
Collapse
|
3
|
Leczycki P, Banach M, Maciejewski M, Bielecka-Dabrowa A. Heart Failure Risk Predictions and Prognostic Factors in Adults With Congenital Heart Diseases. Front Cardiovasc Med 2022; 9:692815. [PMID: 35282364 PMCID: PMC8907450 DOI: 10.3389/fcvm.2022.692815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Abstract
In recent decades the number of adults with congenital heart diseases (ACHD) has increased significantly. This entails the need for scrupulous evaluation of the current condition of these patients. The ACHD population is one of the most challenging in contemporary medicine, especially as well-known scales such as the NYHA classification have very limited application. At the moment, there is a lack of universal parameters or scales on the basis of which we can easily capture the moment of deterioration of our ACHD patients' condition. Hence it is crucial to identify factors that are widely available, cheap and easy to use. There are studies showing more and more potential prognostic factors that may be of use in clinical practice: thorough assessment with echocardiography and magnetic resonance imaging (e.g., anatomy, ventricular function, longitudinal strain, shunt lesions, valvular defects, pericardial effusion, and pulmonary hypertension), cardiopulmonary exercise testing (e.g., peak oxygen uptake, ventilatory efficiency, chronotropic incompetence, and saturation) and biomarkers (e.g., N-terminal pro-brain type natriuretic peptide, growth-differentiation factor 15, high-sensitivity troponin T, red cell distribution width, galectin-3, angiopoietin-2, asymmetrical dimethylarginine, and high-sensitivity C-reactive protein). Some of them are very promising, but more research is needed to create a specific panel on the basis of which we will be able to assess patients with specific congenital heart diseases.
Collapse
Affiliation(s)
- Patryk Leczycki
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- *Correspondence: Patryk Leczycki
| | - Maciej Banach
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Łodź, Poland
| | - Marek Maciejewski
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
| | - Agata Bielecka-Dabrowa
- Department of Cardiology and Congenital Diseases of Adults, Polish Mother's Memorial Hospital Research Institute, Łodź, Poland
- Department of Preventive Cardiology and Lipidology, Medical University of Lodz, Łodź, Poland
| |
Collapse
|
4
|
Gordon B, González-Fernández V, Dos-Subirà L. Myocardial fibrosis in congenital heart disease. Front Pediatr 2022; 10:965204. [PMID: 36467466 PMCID: PMC9715985 DOI: 10.3389/fped.2022.965204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/18/2022] [Indexed: 11/21/2022] Open
Abstract
Myocardial fibrosis resulting from the excessive deposition of collagen fibers through the myocardium is a common histopathologic finding in a wide range of cardiovascular diseases, including congenital anomalies. Interstitial fibrosis has been identified as a major cause of myocardial dysfunction since it distorts the normal architecture of the myocardium and impairs the biological function and properties of the interstitium. This review summarizes current knowledge on the mechanisms and detrimental consequences of myocardial fibrosis in heart failure and arrhythmias, discusses the usefulness of available imaging techniques and circulating biomarkers to assess this entity and reviews the current body of evidence regarding myocardial fibrosis in the different subsets of congenital heart diseases with implications in research and treatment.
Collapse
Affiliation(s)
- Blanca Gordon
- Integrated Adult Congenital Heart Disease Unit, Vall d'Hebron University Hospital-Santa Creu i Sant Pau University Hospital, Barcelona, Spain
| | - Víctor González-Fernández
- Integrated Adult Congenital Heart Disease Unit, Vall d'Hebron University Hospital-Santa Creu i Sant Pau University Hospital, Barcelona, Spain
| | - Laura Dos-Subirà
- Integrated Adult Congenital Heart Disease Unit, Vall d'Hebron University Hospital-Santa Creu i Sant Pau University Hospital, Barcelona, Spain
| |
Collapse
|
5
|
Abstract
The number of rTOF patients who survive into adulthood is steadily rising, with currently more than 90% reaching the third decade of life. However, rTOF patients are not cured, but rather have a lifelong increased risk for cardiac and non-cardiac complications. Heart failure is recognized as a significant complication. Its occurrence is strongly associated with adverse outcome. Unfortunately, conventional concepts of heart failure may not be directly applicable in this patient group. This article presents a review of the current knowledge on HF in rTOF patients, including incidence and prevalence, the most common mechanisms of heart failure, i.e., valvular pathologies, shunt lesions, left atrial hypertension, primary left heart and right heart failure, arrhythmias, and coronary artery disease. In addition, we will review information regarding extracardiac complications, risk factors for the development of heart failure, clinical impact and prognosis, and assessment possibilities, particularly of the right ventricle, as well as management strategies. We explore potential future concepts that may stimulate further research into this field.
Collapse
|
6
|
Late gadolinium enhancement in patients with Tetralogy of Fallot: A systematic review. Eur J Radiol 2021; 136:109521. [PMID: 33450661 DOI: 10.1016/j.ejrad.2021.109521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/09/2020] [Accepted: 01/04/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE The aim of this study is to review the literature concerning myocardial late gadolinium enhancement (LGE) with cardiac magnetic resonance in patients with Tetralogy of Fallot (ToF), with regards to its prevalence, characteristics and clinical relevance. METHODS We performed a systematic search, aiming to retrieve original articles that evaluated LGE in ToF, running a search string on MEDLINE and EMBASE in November 2019 and November 2020. Papers were then selected by two independent, blinded readers based on title and abstract, and then on full-text reading, and articles which did not include LGE evaluation were excluded. From each included paper two readers extracted descriptive data concerning technical parameters of LGE acquisition, LGE description and clinical significance. RESULTS 18 articles were eventually included in our review. The included studies observed that a higher amount of right ventricular LGE relates with higher right ventricular volumes, lower ejection fraction and a higher pulmonary regurgitant fraction, thus acting as a marker of progressive impairment of myocardial function. Moreover, LGE in ToF patients correlated with the onset of arrhythmias, and with serum biomarkers indicative of myocardial stress and fibrosis. CONCLUSIONS LGE could be used in the follow-up repaired ToF patients as its appraisal can provide information concerning cardiac dysfunction. Moreover, it may be ideal to aim towards a common framework for standardizing assessment and quantification of LGE in ToF patients.
Collapse
|
7
|
Cochet H, Iriart X, Allain-Nicolaï A, Camaioni C, Sridi S, Nivet H, Fournier E, Dinet ML, Jalal Z, Laurent F, Montaudon M, Thambo JB. Focal scar and diffuse myocardial fibrosis are independent imaging markers in repaired tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2020; 20:990-1003. [PMID: 30993335 PMCID: PMC6704392 DOI: 10.1093/ehjci/jez068] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/26/2019] [Indexed: 12/17/2022] Open
Abstract
Aims To identify the correlates of focal scar and diffuse fibrosis in patients with history of tetralogy of Fallot (TOF) repair. Methods and results Consecutive patients with prior TOF repair underwent electrocardiogram, 24-h Holter, transthoracic echocardiography, exercise testing, and cardiac magnetic resonance (CMR) including cine imaging to assess ventricular volumes and ejection fraction, T1 mapping to assess left ventricular (LV) and right ventricular (RV) diffuse fibrosis, and free-breathing late gadolinium-enhanced imaging to quantify scar area at high spatial resolution. Structural imaging data were related to clinical characteristics and functional imaging markers. Cine and T1 mapping results were compared with 40 age- and sex-matched controls. One hundred and three patients were enrolled (age 28 ± 15 years, 36% women), including 36 with prior pulmonary valve replacement (PVR). Compared with controls, TOF showed lower LV ejection fraction (LVEF) and RV ejection fraction (RVEF), and higher RV volume, RV wall thickness, and native T1 and extracellular volume values on both ventricles. In TOF, scar area related to LVEF and RVEF, while LV and RV native T1 related to RV dilatation. On multivariable analysis, scar area and LV native T1 were independent correlates of ventricular arrhythmia, while RVEF was not. Patients with history of PVR showed larger scars on RV outflow tract but shorter LV and RV native T1. Conclusion Focal scar and biventricular diffuse fibrosis can be characterized on CMR after TOF repair. Scar size relates to systolic dysfunction, and diffuse fibrosis to RV dilatation. Both independently relate to ventricular arrhythmias. The finding of shorter T1 after PVR suggests that diffuse fibrosis may reverse with therapy.
Collapse
Affiliation(s)
- Hubert Cochet
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France.,Department of Healthcare Technologies, IHU LIRYC, Université de Bordeaux-Inserm, Avenue du Haut Lévêque, 33604, Pessac, France
| | - Xavier Iriart
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Antoine Allain-Nicolaï
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France
| | - Claudia Camaioni
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France
| | - Soumaya Sridi
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France
| | - Hubert Nivet
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France
| | - Emmanuelle Fournier
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Marie-Lou Dinet
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| | - Francois Laurent
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France.,Department of Healthcare Technologies, IHU LIRYC, Université de Bordeaux-Inserm, Avenue du Haut Lévêque, 33604, Pessac, France
| | - Michel Montaudon
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France.,Department of Healthcare Technologies, IHU LIRYC, Université de Bordeaux-Inserm, Avenue du Haut Lévêque, 33604, Pessac, France
| | - Jean-Benoît Thambo
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604 Pessac, France.,Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, 33604, Pessac, France
| |
Collapse
|
8
|
Broberg CS, Khan AM. Fibrosis miocárdica en las cardiopatías congénitas en el adulto. Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2020.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
9
|
van den Bosch E, Cuypers JAAE, Luijnenburg SE, Duppen N, Boersma E, Budde RPJ, Krestin GP, Blom NA, Breur HMPJ, Snoeren MM, Roos-Hesselink JW, Kapusta L, Helbing WA. Ventricular response to dobutamine stress cardiac magnetic resonance imaging is associated with adverse outcome during 8-year follow-up in patients with repaired Tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2020; 21:1039-1046. [PMID: 31596460 PMCID: PMC7440962 DOI: 10.1093/ehjci/jez241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/16/2019] [Accepted: 09/06/2019] [Indexed: 11/15/2022] Open
Abstract
AIMS The aim of this study was to evaluate the possible value of dobutamine stress cardiac magnetic resonance imaging (CMR) to predict adverse outcome in Tetralogy of Fallot (TOF) patients. METHODS AND RESULTS In previous prospective multicentre studies, TOF patients underwent low-dose dobutamine stress CMR (7.5 µg/kg/min). Subsequently, during regular-care patient follow-up, patients were assessed for reaching the composite endpoint (cardiac death, arrhythmia-related hospitalization, or cardioversion/ablation, VO2 max ≤65% of predicted). A normal stress response was defined as a decrease in end-systolic volume (ESV) and increase in ejection fraction. The relative parameter change during stress was calculated as relative parameter change = [(parameterstress - parameterrest)/parameterrest] * 100. The predictive value of dobutamine stress CMR for the composite endpoint was determined using time-to-event analyses (Kaplan-Meier) and Cox proportional hazard analysis. We studied 100 patients [67 (67%) male, median age at baseline CMR 17.8 years (interquartile range 13.5-34.0), age at TOF repair 0.9 years (0.6-2.1)]. After a median follow-up of 8.6 years (6.7-14.1), 10 patients reached the composite endpoint. An abnormal stress response (30% vs. 4.4%, P = 0.021) was more frequently observed in composite endpoint patients. Also in endpoint patients, the relative decrease in right ventricular ESV decreased less during stress compared with the patients without an endpoint (-17 ± 15 vs. -26 ± 13 %, P = 0.045). Multivariable analyses identified an abnormal stress response (hazard ratio 10.4; 95% confidence interval 2.5-43.7; P = 0.001) as predictor for the composite endpoint. CONCLUSION An abnormal ventricular response to dobutamine stress is associated with adverse outcome in patients with repaired TOF.
Collapse
Affiliation(s)
- Eva van den Bosch
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.,Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Judith A A E Cuypers
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Saskia E Luijnenburg
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Nienke Duppen
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Gabriel P Krestin
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Hans M P J Breur
- Division of Pediatric Cardiology, Department of Pediatrics, University Medical Centre Utrecht, Lundlaan 6, 3508 AB Utrecht, The Netherlands
| | - Miranda M Snoeren
- Department of Radiology, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Jolien W Roos-Hesselink
- Department of Cardiology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Livia Kapusta
- Division of Pediatric Cardiology, Department of Pediatrics, Tel Aviv Sourasky Medical Centre, Sackler School of Medicine, Tel Aviv University, Weizmann street, 64239 Tel Aviv, Israel.,Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology, Department of Pediatrics, Erasmus University Medical Center, Doctor Molewaterplein 40, 3000 CM Rotterdam, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.,Division of Pediatric Cardiology, Department of Pediatrics, Radboud University Medical Center, Geert Grooteplein 10, 6500 HB Nijmegen, The Netherlands
| |
Collapse
|
10
|
Broberg CS, Khan AM. Myocardial fibrosis in adult congenital heart disease. ACTA ACUST UNITED AC 2020; 73:707-710. [PMID: 32217067 DOI: 10.1016/j.rec.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 02/06/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Craig S Broberg
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States.
| | - Abigail M Khan
- Adult Congenital Heart Program, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, United States
| |
Collapse
|
11
|
Shade JK, Cartoski MJ, Nikolov P, Prakosa A, Doshi A, Binka E, Olivieri L, Boyle PM, Spevak PJ, Trayanova NA. Ventricular arrhythmia risk prediction in repaired Tetralogy of Fallot using personalized computational cardiac models. Heart Rhythm 2020; 17:408-414. [PMID: 31589989 PMCID: PMC7056519 DOI: 10.1016/j.hrthm.2019.10.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Adults with repaired tetralogy of Fallot (rTOF) are at increased risk for ventricular tachycardia (VT) due to fibrotic remodeling of the myocardium. However, the current clinical guidelines for VT risk stratification and subsequent implantable cardioverter-defibrillator deployment for primary prevention of sudden cardiac death in rTOF remain inadequate. OBJECTIVE The purpose of this study was to determine the feasibility of using an rTOF-specific virtual-heart approach to identify patients stratified incorrectly as being at low VT risk by current clinical criteria. METHODS This multicenter retrospective pilot study included 7 adult rTOF patients who were considered low risk for VT based on clinical criteria. Patient-specific computational heart models were generated from late gadolinium enhanced magnetic resonance imaging (LGE-MRI), incorporating the individual distribution of rTOF fibrotic remodeling in both ventricles. Simulations of rapid pacing determined VT inducibility. Model creation and simulations were performed by operators blinded to clinical outcome. RESULTS Two patients in the study experienced clinical VT. The virtual hearts constructed from LGE-MRI scans of 7 rTOF patients correctly predicted reentrant VT in the models from VT-positive patients and no arrhythmia in those from VT-negative patients. There were no statistically significant differences in clinical criteria commonly used to assess VT risk, including QRS duration and age, between patients who did and those who did not experience clinical VT. CONCLUSION This study demonstrates the feasibility of image-based virtual-heart modeling in patients with congenital heart disease and structurally abnormal hearts. It highlights the potential of the methodology to improve VT risk stratification in patients with rTOF.
Collapse
Affiliation(s)
- Julie K Shade
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark J Cartoski
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Plamen Nikolov
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ashish Doshi
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Edem Binka
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Laura Olivieri
- Division of Cardiology, Children's National Medical Center, Washington, DC
| | - Patrick M Boyle
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland
| | - Philip J Spevak
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; Alliance for Cardiovascular Diagnostic and Treatment Innovation, Whiting School of Engineering and School of Medicine, Johns Hopkins University, Baltimore, Maryland; Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| |
Collapse
|
12
|
Timing of Repair in Tetralogy of Fallot: Effects on Outcomes and Myocardial Health. Cardiol Rev 2020; 29:62-67. [PMID: 31934899 DOI: 10.1097/crd.0000000000000293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Early complete repair of tetralogy of Fallot (ToF) prior to 1 year of age has been demonstrated to be safe and has survival benefits over late repair. The age at repair of ToF affects long-term outcomes. This may largely be related to preserved, or comparatively better, myocardial health. Most studies advocate for an age of repair between 3 and 6 months and certainly below the age of 1 year. Patients with severe right ventricular outflow tract obstruction represent an exception to this rule and may require neonatal repair or surgical and catheter-based palliation before surgery. Older age at repair beyond the first birthday leads to unfavorable right ventricular remodeling with increased right ventricular stiffness and hypertrophy and is associated with increased long-term ventricular tachycardia and all-cause mortality. In this article, we review the short- and long-term benefits of early repair, with a focus on long-term morbidity. In conclusion, we emphasize the importance of myocardial health and the relationship to early repair and advocate for the use of magnetic resonance imaging in adult patients with repaired ToF to detect myocardial fibrosis.
Collapse
|
13
|
Tetralogy of Fallot: risk stratification is straightforward. Or is it? Curr Opin Cardiol 2019; 35:63-69. [PMID: 31574004 DOI: 10.1097/hco.0000000000000693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Tetralogy of Fallot (TOF) carries a long-term risk of arrhythmias and sudden death after surgical repair. Risk stratification is still less accurate than desired. RECENT FINDINGS Several factors have been studied as risk predictors for ventricular arrhythmias and sudden death. Clinical parameters include age at surgery, time since repair, types of previous surgeries, and symptoms such as syncope and palpitations. Electrocardiographic parameters that have been studied include QRS interval, ventricular arrhythmias assessed with Holter monitors, signal averaged ECG, QRS fragmentation, QRS vector magnitude, and microvolt T-wave alternans. Exercising testing has been shown to have prognostic significance. Ventricular function assessment with imaging studies including echocardiography and magnetic resonance imaging (MRI) plays a significant role. Invasive hemodynamic and electrophysiologic studies, in addition to assessment for inducible tachycardia, can provide information regarding the electroanatomic substrate of VT. SUMMARY Risk stratification for TOF has improved over the last years with several clinical, electrocardiographic, imaging, and invasive electrophysiologic findings showing promise, but there still a lack of uniformity in approach between various investigators and reproducibility of findings is difficult in larger populations. With use of a combination of factors, a more informed decision can be made.
Collapse
|
14
|
Hoang TT, Manso PH, Edman S, Mercer-Rosa L, Mitchell LE, Sewda A, Swartz MD, Fogel MA, Agopian AJ, Goldmuntz E. Genetic variants of HIF1α are associated with right ventricular fibrotic load in repaired tetralogy of Fallot patients: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2019; 21:51. [PMID: 31422771 PMCID: PMC6699069 DOI: 10.1186/s12968-019-0555-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/14/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Studies suggest that right ventricular (RV) fibrosis is associated with RV remodeling and long-term outcomes in patients with tetralogy of Fallot (TOF). Pre-operative hypoxia may increase expression of hypoxia inducible factor-1-alpha (HIF1α) and promote transforming growth factor β1 (TGFβ1)-mediated fibrosis. We hypothesized that there would be associations between: (1) RV fibrosis and RV function, (2) HIF1α variants and RV fibrosis, and (3) HIF1α variants and RV function among post-surgical TOF cases. METHODS We retrospectively measured post-surgical fibrotic load (indexed volume and fibrotic score) from 237 TOF cases who had existing cardiovascular magnetic resonance imaging using late gadolinium enhancement (LGE), and indicators of RV remodeling (i.e., ejection fraction [RVEF] and end-diastolic volume indexed [RVEDVI]). Genetic data were available in 125 cases. Analyses were conducted using multivariable linear mixed-effects regression with a random intercept and multivariable generalized Poisson regression with a random intercept. RESULTS Indexed fibrotic volume and fibrotic score significantly decreased RVEF by 1.6% (p = 0.04) and 0.9% (p = 0.03), respectively. Indexed fibrotic volume and score were not associated with RVEDVI. After adjusting for multiple comparisons, 6 of the 48 HIF1α polymorphisms (representing two unique signals) were associated with fibrotic score. None of the HIF1α polymorphisms were associated with indexed fibrotic volume, RVEDVI, or RVEF. CONCLUSION The association of some HIF1α polymorphisms and fibrotic score suggests that HIF1α may modulate the fibrotic response in TOF.
Collapse
Affiliation(s)
- Thanh T. Hoang
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Paulo Henrique Manso
- Department of Pediatrics, Ribeiro Preto Medical School USP, Ribeirao Preto, Brazil
| | - Sharon Edman
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Laura E. Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Anshuman Sewda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Michael D. Swartz
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX USA
| | - Mark A. Fogel
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| |
Collapse
|
15
|
DiLorenzo M, Hwang WT, Goldmuntz E, Ky B, Mercer-Rosa L. Diastolic dysfunction in tetralogy of Fallot: Comparison of echocardiography with catheterization. Echocardiography 2018; 35:1641-1648. [PMID: 30105757 DOI: 10.1111/echo.14113] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 07/12/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Right ventricular (RV) systolic dysfunction has been associated with adverse outcomes in tetralogy of Fallot (TOF). However, the role and etiology of diastolic dysfunction remain incompletely defined. We assessed the association between traditional echocardiographic measures of diastolic function with catheter-based RV end-diastolic pressure (RVEDP) and identified clinical characteristics independently associated with diastolic dysfunction. METHODS Single-center, retrospective cohort study of surgically repaired TOF patients undergoing cardiac catheterization with echocardiograms within 3 months prior to the catheterization. Tricuspid inflow and tissue Doppler measurements (E/A, E/e', and deceleration time) defined diastolic dysfunction, graded as impaired relaxation, pseudonormal, or restrictive physiology. Regression analyses tested associations between echocardiographic parameters, RVEDP, and clinical characteristics. RESULTS Ninety-four subjects were included. Catheterization age was 8.9 years (interquartile range 4.4, 15.9). RVEDP was 9.5 ± 2.5 mm Hg. Sixty-one (65%) subjects had echocardiographic evidence of diastolic dysfunction. RVEDP was not associated with echocardiographic parameters of diastolic function (grade of dysfunction, E/e', or E/A). Higher RVEDP was associated with larger right atrial and RV end-diastolic area, independently of weight and degree of pulmonary or tricuspid regurgitation, though was not associated with indexed right atrial or RV end-diastolic area. Greater number of interim procedures was associated with higher RVEDP, E/e', and the presence of diastolic dysfunction by echocardiography. CONCLUSIONS Diastolic dysfunction, as determined by echocardiography-derived and catheter-based (RVEDP) measures, is prevalent in this TOF population. These measures are not associated with each other; therefore, echocardiographic parameters of diastolic function are not reflective of RVEDP. The development of noninvasive parameters that correlate with filling pressures is required.
Collapse
Affiliation(s)
- Michael DiLorenzo
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork Presbyterian/Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York.,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wei-Ting Hwang
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Bonnie Ky
- Department of Biostatistics and Epidemiology, The University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Medicine, Penn Cardiovascular Institute, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
16
|
Affiliation(s)
- Justin T. Tretter
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew N. Redington
- From the Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| |
Collapse
|
17
|
Advanced Cardiovascular Magnetic Resonance Techniques in Grown-Up Congenital Heart Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2018. [DOI: 10.1007/s12410-018-9449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|