Impaired right and left ventricular function in asymptomatic children with repaired tetralogy of Fallot by two-dimensional speckle tracking echocardiography study

Normal Values for Echocardiographic Myocardial Work in a Large Pediatric Population

BACKGROUND

Echocardiographic myocardial work is a new load-independent echocardiographic technique to quantify left ventricle (LV) systolic performance. Our aim was to establish normal values for echocardiographic myocardial work in a large population of healthy children.

METHODS

For all the subjects 4-, 2-, and 3-chamber-view videos were stored. The following parameters were obtained by offline analysis: the global myocardial work (GMW), the global myocardial constructive work (GCW), the global myocardial wasted work (GWW), and the global myocardial work efficiency (GWE). Age, weight, height, heart rate, and body surface area (BSA) were used as independent variables in the statistical analysis.

RESULTS

In all, 516 healthy subjects (age range, 1 day-18 years; median age, 8.2 ± 5.3 years; 55.8% male; body surface area (BSA) range, 0.16 to 2.12 m2) were included. GWI, GCW, and GWW increased with weight, height, and BSA (ρ ranging from 0.635 to 0.226, p all < 0.01); GWI and GCW positively correlated with age (ρ 0.653 and 0.507). After adjusting for BSA differences, females showed higher mean GWI (p = 0.002) and GCW values (p < 0.001), thus Z-score equations for gender have been presented.

CONCLUSIONS

We provided MW values in a large population of healthy pediatric subjects including lower ages. MW values increased with age and body size and, interestingly, were higher in females than in men. These data cover a gap in current nomograms and may serve as a baseline for the evaluation of MW analysis in children with congenital and acquired heart diseases.

Right Ventricular and Outflow Tract Functional Characteristics After Repair of Tetralogy of Fallot with Major Aortopulmonary Collaterals

This study describes right ventricle (RV) characteristics and right ventricle to pulmonary artery (RV-PA) conduit function pre- and post-repair in patients with tetraology of Fallot with major aortopulmonary collaterals (TOF/MAPCAs). We reviewed patients who underwent single-stage, complete unifocalization, and repair of TOF/MAPCAs between 2006 and 2019 with available pre- and early postoperative echocardiograms. For a subset of patients, 6-12 month follow-up echocardiogram was available. RV and left ventricle (LV) characteristics and RV-PA conduit function were reviewed. Wilcoxon signed rank test and McNemar's test were used. 170 patients were reviewed, 46 had follow-up echocardiograms. Tricuspid valve annular plane systolic excursion (TAPSE) Z-scores were reduced from pre- (Z-score 0.01) to post-repair (Z-score -4.5, p < 0.001), improved but remained abnormal at follow-up (Z-score -4.0, p < 0.001). RV fractional area change (FAC) and LV ejection fraction were not significantly different before and after surgery. Conduit regurgitation was moderate or greater in 11% at discharge, increased to 65% at follow-up. RV-PA conduit failure (severe pulmonary stenosis or severe pulmonary regurgitation) was noted in 61, and 63% had dilated RV (diastolic RV area Z-score > 2) at follow-up. RV dilation correlated with the severe conduit regurgitation (p = 0.018). Longitudinal RV function was reduced after complete repair of TOF/MAPCAs, with decreased TAPSE and preserved FAC and LV ejection fraction. TAPSE improved but did not normalize at follow-up. Severe RV-PA conduit dysfunction was observed prior to discharge in 11% of patients and in 61% at follow-up. RV dilation was common at follow-up, especially in the presence of severe conduit regurgitation.

Speckle tracking echocardiography for diagnosis of right ventricular failure in children with totally corrected tetralogy of Fallot in Sulaimani, Iraq

Objectives

The study was aimed at using speckle tracking echocardiography as a novel technique to diagnose right ventricular failure (RVF) in children with total correction of tetralogy of Fallot (TOF) through surgery.

Methods

A quasi-experimental study was performed at the Children's Heart Hospital of Sulaimani for 9 months. A total of 150 children with completely repaired TOF were enrolled to investigate RVF. Conventional echocardiographic data were recorded, including right ventricular (RV) ejection fraction (EF), tricuspid annular plane systolic excursion (TAPSE), myocardial performance index (MPI), and RV end-systolic and diastolic volume (RVESV and RVEDV). Additionally, speckle tracking was performed for the regional and longitudinal strain and strain rate in four-chamber apical view. RVF diagnosis was determined on the basis of electrocardiography measurement of P-wave dispersion, T-wave dispersion, and QRS duration.

Results

Children with repaired TOF who were diagnosed with RVF through conventional echocardiography exhibited abnormalities with respect to children with normal RV function, including a TAPSE of 1.3 ± 0.11 cm, RVEF of 35.5 ± 6.72, RVESV of 69.8 ± 15.13 ml, RVEDV of 110.1 ± 14.13 ml, MPI of 0.60 ± 0.12, and Pmax of 52.4 ± 14.08. The use of speckle tracking in RVF diagnosis revealed a relatively lower longitudinal strain and strain rate (-12.1 ± 2.3 and -0.9 ± 0.3, respectively) in the children with RVF. Moreover, longitudinal right ventricular strain was positively correlated with TAPSE (r = 0.656) and EF (r = 0.675), and negatively correlated with RVEDV (r = -0.684), RVESV (r = -0.718), MPI (r = -0.735), and Pmax (r = -0.767).

Conclusions

The application of speckle tracking with the longitudinal RV strain and strain rate to estimate RV function in children with repaired TOF is a new advanced method that, compared with conventional echo, significantly improves the diagnosis of regional myocardial deformations and cardiac muscle motion velocity.

Tricuspid valve annular tilt for assessment of pre- and post-intervention right ventricular volume in patients undergoing transcatheter pulmonary valve replacement

INTRODUCTION

Transcatheter pulmonary valve replacement serves as a successful alternative to surgical replacement of a right ventricle to pulmonary artery conduit. Guidelines for recommending transcatheter pulmonary valve replacement depend on MRI right ventricular volumes, which have been correlated to the echocardiographic measure of right ventricular annular tilt. We aim to assess whether right ventricular annular tilt can be a clinically useful alternative tool in the acute and long-term periods after transcatheter pulmonary valve replacement to assess right ventricular health.

METHODS

We reviewed 70 patients who underwent transcatheter pulmonary valve replacement at a single institution. Echocardiographic measurements were obtained prior to transcatheter pulmonary valve replacement, immediately after transcatheter pulmonary valve replacement, and within 6 months to 1 year after transcatheter pulmonary valve replacement. Right ventricular annular tilt measures the angle of the tricuspid valve plane relative to the mitral valve plane at end-diastole in the apical four-chamber view. Right ventricular fractional area change, right ventricular systolic strain, tissue Doppler velocity, and tricuspid annular plane systolic excursion Z-scores were obtained using published methods.

RESULTS

Right ventricular annular tilt decreased significantly immediately after transcatheter pulmonary valve replacement (p = 0.0004), and this reduction in right ventricular volume persisted at the mid-term follow-up (p < 0.0001). Fractional area change did not change significantly after transcatheter pulmonary valve replacement while right ventricular global strain improved at mid-term follow-up despite no significant difference immediately after transcatheter pulmonary valve replacement.

CONCLUSIONS

Right ventricular annular tilt decreases both immediately after transcatheter pulmonary valve replacement and at mid-term follow-up. Right ventricular strain also improved after transcatheter pulmonary valve replacement, corresponding to the improved volume load. Right ventricular annular tilt can be considered as an additional echocardiographic factor to assess right ventricular volume and remodeling after transcatheter pulmonary valve replacement.

The value of myocardial strain imaging in the evaluation of patients with repaired Tetralogy of Fallot: a review of the literature

Tetralogy of Fallot (ToF) is considered to be the most common, complex, cyanotic congenital heart disease (CHD) representing 7-10% of all congenital heart defects, whereas the patients with ToF are the most frequently operated in their early infancy or childhood. Cardiac magnetic resonance (CMR) consists a valuable imaging technique for the diagnosis and serial follow-up of CHD patients. Furthermore, in recent years, advanced echocardiography imaging techniques have come to the fore, aiming to achieve a complete and more accurate evaluation of cardiac function using speckle tracking imaging modalities. We conducted a review of the literature in order to assess the myocardial deformation of patients with repaired ToF (rToF) using echocardiographic and CMR parameters. Patients with rToF have impaired myocardial strain parameters, that are well standardized either with the use of speckle tracking echocardiography or with the use of CMR imaging. Subclinical left ventricular dysfunction (low GLS) and myocardial dyssynchrony are commonly identified in rToF patients. Impaired left atrium (LA) and right atrium (RA) mechanics are, also, a common finding in this study population, but the studies using atrial strain are a lot fewer than those with LV and RV strain. No studies using myocardial work were identified in the literature, as far as rToF patients are concerned, which makes it an ideal field for further investigation.

Evaluation of right ventricle systolic function after tetralogy of Fallot repair: A systematic review comparing cardiac magnetic resonance and global longitudinal strain

BACKGROUND

Most patients who undergo tetralogy of Fallot (TOF) repair experience late right ventricle (RV) dysfunction due to pulmonary valve regurgitation (PVR). Cardiac magnetic resonance (CMR) is the gold standard method for evaluating RV during follow-up. Global longitudinal strain (GLS) has been introduced as a novel method for the assessment of RV dysfunction. We aimed to compare the feasibility of GLS and CMR for assessing RV function after TOF repair.

METHODS

We systematically reviewed the English literature using PubMed, SciELO and Google Scholar for articles published between January 1, 2015, and December 31, 2020. Articles evaluating RV function comparing by GLS and CMR after TOF repair were included.

RESULTS

Nine studies including 465 patients were analyzed. Most patients were men (280; 60%), the male:female ratio was 1.5:1, and the age range was .8 to 57.7 years. The mean follow-up time was 6 to 32 months. The correlation between RV GLS and RV ejection fraction (EF) by CMR was negative for the articles and varied from moderate to strong (r = -.45, r = -.60, r = -.76).

CONCLUSION

Right ventricle GLS can be considered for routine follow-up of TOF repair patients, even though CMR remains the noninvasive gold standard method. Using a single parameter may not allow comparison of the accuracy of 3D RV EF by using CMR and GLS. Further studies with a larger number of patients undergoing TOF repair are required to evaluate the correlation between these examinations.

Evaluation of ventricular function and myocardial deformation in children with repaired tetralogy of Fallot by real-time three-dimensional (four-dimensional) echocardiography

AIM

The left and right ventricular dysfunction are important clinical course indicators in patients with repaired tetralogy of Fallot. This study aimed to evaluate ventricular volumes, functions, and myocardial deformation in children with repaired tetralogy of Fallot by real-time three-dimensional (four-dimensional) echocardiography and compared with healthy children. It also aimed to investigate the relationships between ventricular volumes, functions, and myocardial deformation parameters in the patients.

MATERIALS AND METHODS

In this cross-sectional study, 35 patients (mean age 15.1 ± 2.8 years, 54% male) and 35 healthy controls of similar age, gender, and body measurements underwent echocardiography. End-diastolic volume index, end-systolic volume index, and ejection fractions of both ventricles; global longitudinal, circumferential, radial strain, twist, and torsion of the left ventricle; the longitudinal strain of the right ventricle free wall and septum were measured.

RESULTS

Left ventricular ejection fraction, global circumferential and radial strain, twist and torsion were significantly lower in patients compared with controls. Left ventricular ejection fraction correlated with global circumferential (r = -0.446, p < 0.001) and radial strain (r = -0.433, p < 0.001) in the patients. Right ventricular volumes were significantly higher, and ejection fraction was significantly lower in patients compared with controls. All right ventricular parameters correlated with each other in the patients.

CONCLUSION

Left ventricular contraction pattern was changed, circumferential and radial fibres were most affected in the patients. Right ventricular dilatation and dysfunction were detected, and right ventricular ejection fraction correlated well with strain measurements of the right ventricle.

Biventricular strain and strain rate impairment shortly after surgical repair of tetralogy of Fallot in children: A case-control study

Background

Early biventricular dysfunction in repaired tetralogy of Fallot (TOF) children may lead to poor clinical outcomes. We aimed to assess biventricular function in TOF children before and after surgery by speckle tracking echocardiography (STE) and compare them with the controls.

Methods

Twenty repaired TOF children and 20 normal children as controls were assessed by STE. Tricuspid annular plane systolic excursion (TAPSE), left ventricular ejection fraction (LVEF), biventricular strain, and strain rate were compared before and after surgery and between TOF children and controls.

Results

Postoperative LVEF (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for left ventricle improved significantly compared to preoperative phase. However, postoperative left ventricular strain (p = 0.05) and strain rate (p = 0.01) in TOF children were significantly impaired compared to controls. Postoperative LVEF was correlated inversely with postoperative strain rate (r = −0.40, p = 0.04). Postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.001) for right ventricle significantly worsened when compared with the preoperative phase. Moreover, postoperative TAPSE (p = 0.001), strain (p = 0.001), and strain rate (p = 0.01) were significantly impaired compared to controls. Postoperative right ventricular strain rate was correlated significantly with the weight of children (r = 0.48, p = 0.02), and postoperative left ventricular strain showed significant correlations with aortic clamp time (r = 0.44, p = 0.04) and with ICU stay (r = −0.46, p = 0.04).

Conclusion

Despite normal LVEF, TOF children exhibit impaired left ventricular strain and strain rate after surgery. TAPSE, strain, and strain rate for the right ventricle worsen after surgical repair. STE‐driven strain can be used to detect early ventricular dysfunction and the associated prognostic implications.

Can we Trust in Routine Echocardiography to Assess the Right Ventricle and Pulmonary Insufficiency? A Comparative Study with Cardiac Magnetic Resonance

BACKGROUND

Cardiac magnetic resonance (CMR) is the method of choice for assessing right ventricular (RV) dimensions and function, and pulmonary insufficiency (PI).

OBJECTIVES

To assess the accuracy of two-dimensional echocardiography (2D ECHO) in estimating RV function and dimensions, and the degree of PI, and compare the 2D ECHO and CMR findings.

METHODS

We compared ECHO and CMR reports of patients whose indication for CMR had been to assess RV and PI. A p-value < 0.05 was considered statistically significant.

RESULTS

We included 51 congenital heart disease patients, with a median age of 9.3 years (7-13.3 years). There was poor agreement between 2D ECHO and CMR for classification of the RV dimension (Kappa 0.19; 95% CI 0.05 to 0.33, p 0.004) and function (Kappa 0.16; 95% CI -0.01 to +0.34; p 0.034). The RV was undersized by 2D ECHO in 43% of the cases, and RV function was overestimated by ECHO in 29% of the cases. The degree of agreement between the methods in the classification of PI was not significant (Kappa 0.014; 95% CI -0.03 to +0.06, p 0.27). 2D ECHO tended to overestimate the degree of PI.

CONCLUSIONS

The 2D ECHO showed a low agreement with CMR regarding the RV dimensions and function, and degree of PI. In general, ECHO underestimated the dimensions of the RV and overestimated the function of the RV and the degree of PI as compared with CMR.

Normal Left Ventricular Systolic and Diastolic Strain Rate Values in Children Derived from Two-Dimensional Speckle-Tracking Echocardiography

BACKGROUND

Strain rate (SR) parameters derived from two-dimensional speckle-tracking echocardiography have prognostic value in children with heart disease. Routine use is hindered by a lack of normative data. The aim of this study was to determine reference values and Z scores for left ventricular systolic and diastolic SR in a large cohort of healthy children.

METHODS

Echocardiograms from 577 subjects ≤18 years of age (mean age, 9.6 ± 5.6 years; range, 1 day to 18.0 years; 46% female) with structurally and functionally normal hearts were retrospectively included. Left ventricular longitudinal and circumferential systolic and early and late diastolic SR were measured using two-dimensional speckle-tracking echocardiography from the apical four-chamber and short-axis mid-papillary views. Associations with age and body surface area were assessed using Spearman correlation and generalized additive modeling. The relationship between systolic SR and wall stress (afterload) was examined. Analyses were conducted with and without correction for heart rate. Multivariable linear regression modeling was used to identify independent factors associated with the SR parameters. Z score equations were derived from a selected best-fit parametric model.

RESULTS

All SR parameters differed significantly by age group. The magnitude of all SR values decreased with increasing age and body surface area. Systolic SR magnitude was inversely related to wall stress in children ≤7 years of age but not did not vary significantly in the older age groups. All relationships were maintained after heart rate correction. SR measurements had very good or excellent agreement.

CONCLUSION

Longitudinal and circumferential systolic and diastolic SR parameters are presented from a large cohort of healthy children using two-dimensional speckle-tracking echocardiography from the Philips platform. SR values differ significantly by age and body surface area. These results suggest that the myocardium becomes less sensitive to afterload with maturity. Z score equations based on age are presented, which should promote further clinical and research use.

Right Ventricular Damage in COVID-19: Association Between Myocardial Injury and COVID-19

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, is a global pandemic. It has resulted in considerable morbidity and mortality around the world. The respiratory system is the main system invaded by the virus involved in COVID-19. In addition to typical respiratory manifestations, a certain proportion of severe COVID-19 cases present with evidence of myocardial injury, which is associated with excessive mortality. With availability of an increasing amount of imaging data, right ventricular (RV) damage is prevalent in patients with COVID-19 and myocardial injury, while left ventricular damage is relatively rare and lacks specificity. The mechanisms of RV damage may be due to increased RV afterload and decreased RV contractility caused by various factors, such as acute respiratory distress syndrome, pulmonary thrombosis, direct viral injury, hypoxia, inflammatory response and autoimmune injury. RV dysfunction usually indicates a poor clinical outcome in patients with COVID-19. Timely and effective treatment is of vital importance to save patients' lives as well as improve prognosis. By use of echocardiography or cardiovascular magnetic resonance, doctors can find RV dilatation and dysfunction early. By illustrating the phenomenon of RV damage and its potential pathophysiological mechanisms, we will guide doctors to give timely medical treatments (e.g., anticoagulants, diuretics, cardiotonic), and device-assisted therapy (e.g., mechanical ventilation, extracorporeal membrane oxygenation) when necessary for these patients. In the paper, we examined the latest relevant studies to investigate the imaging features, potential mechanisms, and treatments of myocardial damage caused by COVID-19. RV damage may be an association between myocardial damage and lung injury in COVID-19. Early assessment of RV geometry and function will be helpful in aetiological determination and adjustment of treatment options.

Right Ventricular Remodeling in Hypoplastic Left Heart Syndrome is Minimally Impacted by Cardiopulmonary Bypass: A Comparison of Norwood vs. Hybrid

Right ventricular (RV) remodeling in hypoplastic left heart syndrome (HLHS) begins prenatally and continues through staged palliations. However, it is unclear if the most marked observed remodeling post-Norwood is secondary to cardiopulmonary bypass (CPB) exposure or if it is an adaptation intrinsic to the systemic RV. This study aims to determine the impact of CPB on RV remodeling in HLHS. Echocardiograms of HLHS survivors undergoing stage 1 Norwood (n = 26) or Hybrid (n = 20) were analyzed at pre- and post-stage 1, pre- and post-bidirectional cavo-pulmonary anastomosis (BCPA), and pre-Fontan. RV fractional area change (FAC), vector velocity imaging for longitudinal & derived circumferential deformation (global radial shortening (GRS) = peak radial displacement/end-diastolic diameter), and deformation ratio (longitudinal/ circumferential) were assessed. Both groups had similar age, clinical status and functional parameters pre-stage 1. No difference in RV size and sphericity at any stage between groups. RVFAC was normal (> 35%) throughout for both groups. Both Norwood and Hybrid patients had increased GRS (p = 0.0001) post-stage 1 and corresponding unchanged longitudinal strain, resulting in decreased deformation ratio (greater relative RV circumferential contraction), p = 0.0001. Deformation ratio remained decreased in both groups in subsequent stages. Irrespective of timing of the first CPB exposure, both Norwood and Hybrid patients underwent similar RV remodeling, with relative increase in circumferential to longitudinal contraction soon after stage 1 palliation. The observed RV remodeling in HLHS survivors were minimally impacted by CPB.

[Right ventricular systolic dysfunction as a predictor of adverse outcome in patients with COVID-19]

Aim To analyze survival of patients with COVID-19 based on echocardiographic (EchoCG) criteria for evaluation of the right ventricular (RV) systolic function.Material and methods Data of patients were retrospectively evaluated at the Center for Medical Care of Patients with Coronavirus Infection. Among 142 primarily evaluated patients with documented COVID-19, 110 patients (men/women, 63/47; mean age, 62.3 ± 15.3 years) met inclusion/exclusion criteria. More than 30 EchoCG parameters were analyzed, and baseline data (comorbidities, oxygen saturation, laboratory data, complications, outcomes, etc.) were evaluated. ROC-analysis was used for evaluating the diagnostic significance of different EchoCG parameters for prediction of a specific outcome and its probability. Dependence of the overall survival of patients on different EchoCG parameters was analyzed with the Cox proportional hazards model. For assessing the predictive value of EchoCG parameters for patient stratification by risk of an adverse outcome, a predictive model was developed using the CHAID method.Results The in-hospital death rate of patients included into the study was 15.5 %, and the death rate for this period of in-hospital observation was 12 %. Based on the single-factor analysis of EchoCG parameters, a multifactor model was developed using the method of Cox regression. The model included two predictors for an unfavorable outcome, estimated pulmonary artery systolic pressure (EPASP) and maximal indexed right atrial volume (RAi), and a preventive factor, right ventricular global longitudinal strain (LS RV). Base risks for fatal outcome were determined with an account of the follow-up time. According to the obtained values, an increase in EPASP by 1 mm Hg was associated with increases in the risk of fatal outcome by 8.6 % and in the RA(i) volume by 1 ml/5.8 %. LS RV demonstrated an inverse correlation; a 1% increase in LS RV was associated with a 13.4% decrease in the risk for an unfavorable outcome. According to the ROC analysis, the most significant determinants of the outcome were the tricuspid annular plane systolic excursion (TAPSE) (AUC, 0.84 ± 0.06; cut-off, 18 mm) and EPASP (AUC, 0.86 ± 0.05; cut-off, 42 mm Hg). Evaluating the effects of different EchoCG predictors, that characterized the condition of the right heart, provided a classification tree. Six final decisions were determined in the model, two of which were assigned to the category of reduced risk for fatal outcome and four were assigned to the category of increased risk. Sensitivity of the classification tree model was 94.1 % and specificity was 89.2 %. Overall diagnostic significance was 90.0±2.9 %.Conclusion The presented models for statistical treatment of EchoCG parameters reflect the requirement for a comprehensive analysis of EchoCG parameters based on a combination of standard methods for EchoCG evaluation and current technologies of noninvasive visualization. According to the study results, the new EchoCG marker, LS RV, allows identifying the signs of right ventricular dysfunction (particularly in combination with pulmonary hemodynamic indexes), may enhance the early risk stratification in patients with COVID-19, and help making clinical decisions for patients with different acute cardiorespiratory diseases.

Prognostic Value of Right Ventricular Longitudinal Strain in Patients With COVID-19

Objectives

The aim of this study was to investigate whether right ventricular longitudinal strain (RVLS) was independently predictive of higher mortality in patients with coronavirus disease-2019 (COVID-19).

Background

RVLS obtained from 2-dimensional speckle-tracking echocardiography has been recently demonstrated to be a more accurate and sensitive tool to estimate right ventricular (RV) function. The prognostic value of RVLS in patients with COVID-19 remains unknown.

Methods

One hundred twenty consecutive patients with COVID-19 who underwent echocardiographic examinations were enrolled in our study. Conventional RV functional parameters, including RV fractional area change, tricuspid annular plane systolic excursion, and tricuspid tissue Doppler annular velocity, were obtained. RVLS was determined using 2-dimensional speckle-tracking echocardiography. RV function was categorized in tertiles of RVLS.

Results

Compared with patients in the highest RVLS tertile, those in the lowest tertile were more likely to have higher heart rate; elevated levels of D-dimer and C-reactive protein; more high-flow oxygen and invasive mechanical ventilation therapy; higher incidence of acute heart injury, acute respiratory distress syndrome, and deep vein thrombosis; and higher mortality. After a median follow-up period of 51 days, 18 patients died. Compared with survivors, nonsurvivors displayed enlarged right heart chambers, diminished RV function, and elevated pulmonary artery systolic pressure. Male sex, acute respiratory distress syndrome, RVLS, RV fractional area change, and tricuspid annular plane systolic excursion were significant univariate predictors of higher risk for mortality (p < 0.05 for all). A Cox model using RVLS (hazard ratio: 1.33; 95% confidence interval [CI]: 1.15 to 1.53; p < 0.001; Akaike information criterion = 129; C-index = 0.89) was found to predict higher mortality more accurately than a model with RV fractional area change (Akaike information criterion = 142, C-index = 0.84) and tricuspid annular plane systolic excursion (Akaike information criterion = 144, C-index = 0.83). The best cutoff value of RVLS for prediction of outcome was -23% (AUC: 0.87; p < 0.001; sensitivity, 94.4%; specificity, 64.7%).

Conclusions

RVLS is a powerful predictor of higher mortality in patients with COVID-19. These results support the application of RVLS to identify higher risk patients with COVID-19.

Tetralogy of Fallot: cardiac imaging evaluation

Thanks to advances in pediatric cardiology, most infants with tetralogy of Fallot (TOF) now survive into adulthood. This relatively new population of adult patients may face long-term complications, including pulmonary regurgitation (PR), right ventricular (RV) tract obstruction, residual shunts, RV dysfunction, and arrythmias. They will often need to undergo pulmonary valve (PV) replacement and other invasive re-interventions. However, the optimal timing for these procedures is challenging, largely due to the complexity of evaluating RV volume and function. The options for the follow-up of these patients have rapidly evolved from an angiography-based approach to the surge of advanced imaging techniques, mainly echocardiography, cardiac magnetic resonance (CMR), and computer tomography (CT). In this review, we outline the indications, strengths and limitations of these modalities in the adult TOF population.

Ventricular Myocardial Deformation Imaging of Patients with Repaired Tetralogy of Fallot

In patients with repaired tetralogy of Fallot (TOF), dysfunction of the right and left ventricles remains an important issue. Adverse right ventricular (RV) remodeling has been related to RV dilation secondary to pulmonary regurgitation, electromechanical dyssynchrony, and myocardial fibrosis. Left ventricular (LV) dysfunction is attributed among other factors to altered ventricular-ventricular interaction. Advancements in echocardiography and cardiac magnetic resonance imaging have enabled direct interrogation of myocardial deformation of both ventricles in terms of myocardial strain and strain rate. Emerging evidence suggests that myocardial deformation imaging may provide incremental information for clinical use. In children and adults with repaired TOF, there is a growing body of literature on the use of myocardial deformation imaging in the assessment of ventricular mechanics and its clinical and prognostic values. The present review aims to provide an overview of impairment in RV and LV mechanics, associations between RV and LV deformation, changes in ventricular deformation after pulmonary valve replacement, and associations between measures of RV and LV deformation and outcomes and to highlight the clinical translational potential of myocardial deformation imaging in patients with repaired TOF.

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.

Serial assessment of postoperative ventricular mechanics in young children with tetralogy of Fallot: Comparison of transannular patch and valve-sparing repair

BACKGROUND

Little is known about the early time course of biventricular function and mechanics after tetralogy of Fallot (TOF) repair. We sought to evaluate and describe the evolution of the right ventricle (RV) after TOF repair in young infants and children using conventional echocardiographic parameters and global longitudinal strain (GLS).

METHODS

A retrospective review was performed of all patients with TOF and pulmonary stenosis who underwent repair from January 2002 to September 2015 and had at least 3 serial postsurgical echocardiograms spanning from infancy to early childhood (<8 years). Student's t test was performed to compare patients who underwent valve sparing (VS) versus transannular patch (TAP) repair. ANOVA was used to track measures of ventricular systolic function over time.

RESULTS

We analyzed 151 echocardiograms performed on 42 patients. Pulmonary regurgitation (PR, moderate or severe) and the RV to left ventricular (LV) basal dimension ratio were higher in TAP patients (P < .04 at all-time points). Along with a significant increase in RV basal diameter Z-score in the TAP group (P < .001), there was an improvement in RV and LV GLS over time in both groups (P < .001). The LV GLS at last follow-up was lower in patients who underwent reoperation than those who did not (P = .050). LV GLS at the last follow-up echocardiogram was lower in patients with significant PR than those without (P < .001).

CONCLUSIONS

Ventricular function appeared improve over time from the initial postoperative period in TOF patients. TAP repair was associated with a progressively higher RV/LV ratio in young children. GLS and RV/LV basal diameter ratio may be useful when following young children after TOF repair. Further research is necessary to understand the trajectory of ventricular functional and volumetric changes in young children in order to provide the most effective lifetime management of patients with TOF.

Use of Speckle Tracking Echocardiography to Assess Left Ventricular Systolic Function in Patients with Surgically Repaired Tetralogy of Fallot: Global and Segmental Assessment

Patients with repaired Tetralogy of Fallot (rToF) can have significant right and left ventricular dysfunction which can impact clinical outcome. Conventional echocardiographic evaluation using ejection fraction can be limited in detecting early stages of deteriorating left ventricular (LV) systolic function. Speckle-tracking echocardiography (STE) provides a promising emerging tool for early detection of LV systolic dysfunction. The aim of this cross-sectional study is to evaluate the left ventricular global and regional function using STE in rToF patients with preserved left ventricular ejection fraction to detect early signs of LV dysfunction. The study is a retrospective review of the medical records and transthoracic echocardiograms of rTOF patients who were seen in the pediatric cardiology clinic at our institution from August 2016 till May 2018. The rTOF group was compared with a matched healthy control group. Offline strain analysis of TTE studies was completed in each subject according to mode set by the American Society of Echocardiography. Twenty-two patients with rTOF and 22 age-matched controls (rTOF 18.7 ± 6 years and control 14.6 ± 9.6 years, P value 0.19) were included during the study period. The rTOF group consisted of 12 males and 10 females, whereas the control group consisted of 15 males and 7 females. There was no significant difference in terms of LV ejection fraction using both 2-chamber as well as 4-chamber views. Global LV longitudinal strain was significantly lower in the rTOF group compared with the control group (rTOF - 15.92 ± 3.16 vs control - 22.79 ± 2.45, P value 0.00). All 17 segments showed significantly lower longitudinal strains in rTOF group compared with the control group. Global circumferential left ventricle strain was significantly lower in the rTOF patients compared with the control group (- 17.24 ± 5.86 vs - 22.74 ± 3.99, P value 0.001). 13 out of 16 segments had lower circumferential strains in the rTOF patients compared with controls. Asymptomatic surgically repaired TOF patients exhibited abnormal segmental and global left ventricle longitudinal and circumferential strains despite having normal left ventricle ejection fraction. Our findings suggest subclinical damage to the left ventricle systolic function post-surgical repair of TOF. 2-D speckle-tracking echocardiography may be used as a valuable method in the early recognition of left myocardial systolic function impairment in patients after TOF repair. The application of this method to guide clinical decision and management of rTOF patients such as earlier pulmonary valve replacement or risk stratification for sudden cardiac death needs further investigation.

Three-dimensional analysis of regional right ventricular shape and function in repaired tetralogy of Fallot using cardiovascular magnetic resonance

BACKGROUND

Patients with surgically repaired tetralogy of Fallot (rTOF) often have residual pulmonic valve regurgitation, leading to abnormal remodeling and dysfunction of the right ventricle often requiring pulmonic valve replacement. We tested the hypothesis that 3D analysis of right ventricular (RV) shape and function may reveal differences in regional adaptive remodeling that occurs in patients with rTOF, depending on whether a transannular patch (TAP) was utilized.

METHODS

Forty patients with rTOF who underwent cardiac magnetic resonance imaging (1.5 T), including 20 with and 20 without TAP, and 10 normal controls were studied. Images were analyzed to measure RV endocardial curvature and global and regional volume and function.

RESULTS

RV ejection fraction (EF) was 42 ± 11% in TAP and 38 ± 9% in no-TAP (p = 0.19), both lower than 54 ± 3% in controls (p < 0.01). Left ventricular (LV) EF was 54 ± 9% in TAP, 54 ± 8% in no-TAP (p = 0.87) and 61 ± 16% in controls (both p < 0.01). Indexed LV end-diastolic volumes were higher in no-TAP than in TAP subgroup (p = 0.02). With TAP, mid RV septum showed lower curvature during diastole (less convex), than the mid and apical free walls and free wall adjacent to the RV outflow tract (RVOT; more convex). There were no differences in curvature during systole between rTOF subgroups but mid and RVOT free walls showed higher curvature versus controls.

CONCLUSIONS

This is the first study to comprehensively describe the influence of TAP on changes in regional RV shape in patients with rTOF. Understanding these differences may help guide therapeutic options for residual pulmonary valve regurgitation in rTOF patients.

Longitudinal Changes in Right Ventricular Function in Tetralogy of Fallot in the Initial Years after Surgical Repair

BACKGROUND

Right ventricular (RV) dysfunction is associated with adverse long-term outcomes in patients with tetralogy of Fallot. Little is known about RV function in the first years after surgical repair. The aim of this study was to investigate perioperative changes in myocardial deformation using global longitudinal strain.

METHODS

A retrospective analysis of patients with surgically repaired tetralogy of Fallot was performed. Global longitudinal peak systolic RV strain was measured on early postoperative echocardiograms, two subsequent postoperative echocardiograms through 2 years postoperatively, and preoperative echocardiograms, when available. Preoperative and late follow-up strain was compared with strain in 0- to 8-month-old and 1- to 4-year-old control subjects, respectively.

RESULTS

Forty-seven patients were included. Compared with postoperative strain (7 ± 7 days postoperatively), strain at follow-up 1 (8.3 ± 4 months postoperatively) was significantly improved (-12.3 ± 3.3% vs -18.8 ± 2.5%, P < .001), with no additional improvement 23.2 ± 6 months postoperatively (-18.8 ± 2.5% vs -19.8 ± 3.1%, P = .12). Postoperative strain was worse than preoperative strain (n = 25, -12.5 ± 3.6% vs -18.4 ± 2.9%, P < .001). Compared with control subjects, preoperative strain was similar (-19.3 ± 3.8% vs -18.4 ± 2.9%, P = .30), though late follow-up strain was significantly worse (-27.7 ± 2.8% vs -19.8 ± 3.1%, P < .001).

CONCLUSIONS

RV global longitudinal strain worsens in the early postoperative period following surgical repair of tetralogy of Fallot but recovers through 2 postoperative years. Despite recovery to preoperative values, the presence of RV dysfunction compared with control subjects suggests that long-term dysfunction may begin early. The trajectory of RV dysfunction through the later years needs further study.

Histologic and Hemodynamic Correlates of Right Ventricular Function in a Pressure Overload Model: a Study Using Three-Dimensional Speckle Tracking Echocardiography

The aim of our study was to assess the characterization of right ventricular (RV) deformation using three-dimensional (3D) speckle tracking echocardiography (STE) and association of 3D-STE indices with histologic and hemodynamic parameters in a chronic RV pressure overload animal model. Pulmonary artery banding (PAB) was used to induce RV pressure overload in seven beagles. 3D-STE, histologic and hemodynamic measurements were performed in PAB and sham-operated beagles 3 mo after PAB. RV longitudinal, radial and circumferential strain was measured from 3D-STE. Three mo after PAB, RV longitudinal strain was decreased; whereas radial and circumferential strain remained unchanged in PAB group. RV longitudinal strain was associated with interstitial fibrosis (r = -0.733) in the endocardial layer of the RV free wall. RV circumferential strain was related to dp/dt_max (r = 0.718). The significant correlations of RV 3D-STE indices with histologic and hemodynamic parameters indicate that 3D-STE may be a valuable tool for assessment of ventricular function in RV pressure overload.

Isolated pulmonary regurgitation causes decreased right ventricular longitudinal function and compensatory increased septal pumping in a porcine model

Aim

Longitudinal ventricular contraction is a parameter of cardiac performance with predictive power. Right ventricular (RV) longitudinal function is impaired in patients with free pulmonary regurgitation (PR) following corrective surgery for Tetralogy of Fallot (TOF). It remains unclear whether this is a consequence of the surgical repair, or whether it is inherent to PR. The aim of this study was to assess the relationship between longitudinal, lateral and septal pumping in a porcine model of isolated PR.

Methods

Piglets were divided into a control (n = 8) group and a treatment (n = 12) group, which received a stent in the pulmonary valve orifice, inducing PR. After 2–3 months, animals were subjected to cardiac magnetic resonance imaging. A subset of animals (n = 6) then underwent percutaneous pulmonary valve replacement (PPVR) with follow‐up 1 month later. Longitudinal, lateral and septal contributions to stroke volume (SV) were quantified by measuring volumetric displacements from end‐diastole to end‐systole in the cardiac short axis and long axis.

Results

PR resulted in a lower longitudinal contribution to RV stroke volume, compared to controls (60.0 ± 2.6% vs. 73.6 ± 3.8%; P = 0.012). Furthermore, a compensatory increase in septal contribution to RVSV was observed (11.0 ± 1.6% vs. −3.1 ± 1.5%; P < 0.0001). The left ventricle (LV) showed counter‐regulation with an increased longitudinal LVSV. Changes in RV longitudinal function were reversed by PPVR.

Conclusion

These findings suggest that PR contributes to decreased RV longitudinal function in the absence of scarring from cardiac surgery. Measurement of longitudinal RVSV may aid risk stratification and timing for interventional correction of PR in TOF patients.

Impact of surgical correction of tetralogy of fallot on short-term right and left ventricular function as determined by 2-dimensional speckle tracking echocardiography

Right ventricular (RV) and left ventricular (LV) dysfunction is an important determinant of poor clinical status in repaired patients with tetralogy of Fallot (TOF). The purpose of our study is to assess the impact of surgical repair on short-term RV and LV function by 2-dimensional speckle tracking echocardiography (STE).Sixty-seven patients (median age 12 months) with TOF before and 6 months after repair and 35 healthy subjects were studied. The patients were divided into the younger (age at surgery ≤12 months) and older (age at surgery >12 months) subgroups. RV and LV global longitudinal systolic strain and strain rate (SR), and LV global circumferential and radial systolic strain and SR were measured by STE. After repair, RV longitudinal strain and SR increased in the younger patients, whereas RV longitudinal SR was decreased in the older patients. LV deformation parameters were unchanged in all patients. In the multivariate analysis, patients with better RV and LV deformation parameters preoperatively were identified to have better RV and LV strain and SR postoperatively (P < 0.05 for all). The surgical approach of the pulmonary valve ring was predictive of RV and LV systolic function postoperatively (P < 0.05 for all).After TOF repair, short-term RV function improvement is identified in the younger but not in the older patients, whereas LV function is unchanged in all patients. The preoperative RV and LV deformational indices are the determinant of postoperative biventricular function improvement. STE appears to be a valuable tool for assessment of biventricular function after congenital heart disease surgery.

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.

How best to assess right ventricular function by echocardiography

Right ventricular function is a crucial determinant of long-term outcomes of children with heart disease. Quantification of right ventricular systolic and diastolic performance by echocardiography is of paramount importance, given the prevalence of children with heart disease, particularly those with involvement of the right heart, such as single or systemic right ventricles, tetralogy of Fallot, and pulmonary arterial hypertension. Identification of poor right ventricular performance can provide an opportunity to intervene. In this review, we will go through the different systolic and diastolic indices, as well as their application in practice. Quantification of right ventricular function is possible and should be routinely performed using a combination of different measures, taking into account each disease state. Quantification is extremely useful for individual patient follow-up. Laboratories should continue to strive to optimise reproducibility through quality improvement and quality assurance efforts in addition to investing in technology and training for new, promising techniques, such as three-dimensional echocardiography.