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Kozicka UA, Kożuch K, Sadowski K, Gupta T, Hoffman P, Szymański P, Kowalski M, Lipczyńska M. Long-term myocardial performance of the systemic right ventricle during exercise in patients with transposition of the great arteries and atrial switch operation. Hellenic J Cardiol 2024:S1109-9666(24)00174-X. [PMID: 39128709 DOI: 10.1016/j.hjc.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 06/22/2024] [Accepted: 08/04/2024] [Indexed: 08/13/2024] Open
Abstract
The most common clinical scenario in which RV is systemic, is dextroposition transposition of the great arteries (dTGA). This is the second most common cyanotic congenital heart disease [2]. Before the arterial switch operation was introduced in 1975 [3], patients with dTGA were treated with the Mustard or Senning procedure, also referred to as the atrial switch operation, where the systemic veins are routed to the subpulmonary morphological left ventricle and the pulmonary veins are routed to the systemic right ventricle [4].The atrial switch operation leaves the RV in a systemic position, leading to gradual RV dysfunction and RV failure [5-8]. In this context, sRV functional reserve and its ability to augment performance with exercise performance is not well studied.
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Affiliation(s)
- Urszula Alicja Kozicka
- Clinical Cardiology Centre, National Medical Institute of the Interior and Administration, Warsaw, Poland
| | | | - Krzysztof Sadowski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Tripti Gupta
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Piotr Hoffman
- Department of Congenital Heart Diseases, Cardinal Wyszynski National Institute of Cardiology,Warsaw, Poland
| | - Piotr Szymański
- Clinical Cardiology Centre, National Medical Institute of the Interior and Administration, Warsaw, Poland; Center of Postgraduate Medical Education, Warsaw, Poland
| | - Mirosław Kowalski
- Department of Congenital Heart Diseases, Cardinal Wyszynski National Institute of Cardiology,Warsaw, Poland
| | - Magdalena Lipczyńska
- Department of Congenital Heart Diseases, Cardinal Wyszynski National Institute of Cardiology,Warsaw, Poland
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2
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Santens B, Van De Bruaene A, De Meester P, Claessen G, Moons P, Claus P, Goetschalckx K, Bogaert J, Budts W. Decreased cardiac reserve in asymptomatic patients after arterial switch operation for transposition of the great arteries. Int J Cardiol 2023; 388:131153. [PMID: 37433406 DOI: 10.1016/j.ijcard.2023.131153] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/13/2023] [Accepted: 07/05/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Exercise capacity is impaired in patients after arterial switch operation (ASO) for complete transposition of the great arteries. Maximal oxygen consumption is related with outcome. OBJECTIVES This study assessed ventricular function by advanced echocardiography and cardiac magnetic resonance (CMR) imaging at rest and during exercise, to determine exercise capacity in ASO patients, and to correlate exercise capacity with ventricular function as potential early marker of subclinical impairment. METHODS Forty-four patients (71% male, mean age 25 ± 4 years - range 18-40 years) were included during routine clinical follow-up. Assessment involved physical examination, 12‑lead ECG, echocardiography, and cardiopulmonary exercise test (CPET) (day 1). On day 2 CMR imaging at rest and during exercise was performed. Blood was sampled for biomarkers. RESULTS All patients reported New York Heart Association class I, the overall cohort had an impaired exercise capacity (80 ± 14% of predicted peak oxygen consumption). Fragmented QRS was present in 27%. Exercise CMR showed that 20% of patients had abnormal contractile reserve (CR) of the left ventricle (LV) and 25% had reduced CR of the right ventricle (RV). CR LV and CR RV were significantly associated with impaired exercise capacity. Pathological patterns on myocardial delayed enhancement and hinge point fibrosis were detected. Biomarkers were normal. CONCLUSION This study found that in some asymptomatic ASO patients electrical, LV and RV changes at rest, and signs of fibrosis are present. Maximal exercise capacity is impaired and seems to be linearly related to the CR of the LV and the RV. Therefore, exercise CMR might play a role in detecting subclinical deterioration of ASO patients.
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Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Guido Claessen
- Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium; Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Belgium
| | | | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Belgium.
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3
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Ciuca C, Balducci A, Angeli E, Di Dio M, Assenza GE, Mariucci E, Ragni L, Lovato L, Niro F, Gesuete V, Careddu L, Bartolacelli Y, Bulgarelli A, Donti A, Gargiulo GD. Long Term Follow-Up of Patients with Systemic Right Ventricle and Biventricular Physiology: A Single Centre Experience. J Cardiovasc Dev Dis 2023; 10:219. [PMID: 37233186 PMCID: PMC10218798 DOI: 10.3390/jcdd10050219] [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: 02/21/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND A progressively increasing prevalence of congenital heart disease (CHD) in adulthood has been noticed in recent decades; CHD cases with a systemic right ventricle have a poorer outcome. METHODS Seventy-three patients with SRV evaluated in an outpatient clinic between 2014 and 2020 were enrolled in this study. Thirty-four patients had a transposition of the great arteries treated with an atrial switch operation; 39 patients had a congenitally corrected transposition of the great arteries (ccTGA). RESULTS Mean age at the first evaluation was 29.6 ± 14.2 years; 48% of the patients were female. The NYHA class at the visit was III or IV in 14% of the cases. Thirteen patients had at least one previous pregnancy. In 25% of the cases, complications occurred during pregnancy. Survival free from adverse events was 98.6% at one year and 90% at 6-year follow-up without any difference between the two groups. Two patients died and one received heart transplantation during follow-up. The most common adverse event during follow-up was the presence of arrhythmia requiring hospitalization (27.1%), followed by heart failure (12.3%). The presence of LGE together with lower exercise capacity, higher NYHA class and more dilated and/or hypokinetic RV predicted a poorer outcome. Quality of life was similar to the QoL of the Italian population. CONCLUSIONS Long-term follow-up of patients with a systemic right ventricle is characterized by a high incidence of clinical events, prevalently arrhythmias and heart failure, which cause most of the unscheduled hospitalizations.
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Affiliation(s)
- Cristina Ciuca
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Anna Balducci
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Emanuela Angeli
- Pediatric Cardiac Surgery and Adult Congenital Heart Disease, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Mariateresa Di Dio
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Gabriele Egidy Assenza
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Elisabetta Mariucci
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Ragni
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luigi Lovato
- Radiology Unit, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Fabio Niro
- Radiology Unit, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Valentina Gesuete
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Lucio Careddu
- Pediatric Cardiac Surgery and Adult Congenital Heart Disease, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ylenia Bartolacelli
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ambra Bulgarelli
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Andrea Donti
- Pediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Gaetano Domenico Gargiulo
- Pediatric Cardiac Surgery and Adult Congenital Heart Disease, Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Alenezi F, Covington TA, Mukherjee M, Mathai SC, Yu PB, Rajagopal S. Novel Approaches to Imaging the Pulmonary Vasculature and Right Heart. Circ Res 2022; 130:1445-1465. [PMID: 35482838 PMCID: PMC9060389 DOI: 10.1161/circresaha.121.319990] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
There is an increased appreciation for the importance of the right heart and pulmonary circulation in several disease states across the spectrum of pulmonary hypertension and left heart failure. However, assessment of the structure and function of the right heart and pulmonary circulation can be challenging, due to the complex geometry of the right ventricle, comorbid pulmonary airways and parenchymal disease, and the overlap of hemodynamic abnormalities with left heart failure. Several new and evolving imaging modalities interrogate the right heart and pulmonary circulation with greater diagnostic precision. Echocardiographic approaches such as speckle-tracking and 3-dimensional imaging provide detailed assessments of regional systolic and diastolic function and volumetric assessments. Magnetic resonance approaches can provide high-resolution views of cardiac structure/function, tissue characterization, and perfusion through the pulmonary vasculature. Molecular imaging with positron emission tomography allows an assessment of specific pathobiologically relevant targets in the right heart and pulmonary circulation. Machine learning analysis of high-resolution computed tomographic lung scans permits quantitative morphometry of the lung circulation without intravenous contrast. Inhaled magnetic resonance imaging probes, such as hyperpolarized 129Xe magnetic resonance imaging, report on pulmonary gas exchange and pulmonary capillary hemodynamics. These approaches provide important information on right ventricular structure and function along with perfusion through the pulmonary circulation. At this time, the majority of these developing technologies have yet to be clinically validated, with few studies demonstrating the utility of these imaging biomarkers for diagnosis or monitoring disease. These technologies hold promise for earlier diagnosis and noninvasive monitoring of right heart failure and pulmonary hypertension that will aid in preclinical studies, enhance patient selection and provide surrogate end points in clinical trials, and ultimately improve bedside care.
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Affiliation(s)
- Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | | | | | - Steve C. Mathai
- Johns Hopkins Division of Pulmonary and Critical Care Medicine, Baltimore, MD
| | - Paul B. Yu
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
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5
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Cheng S, Li VWY, Cheung YF. Systolic and diastolic functional reserve of the subpulmonary and systemic right ventricles as assessed by pharmacologic and exercise stress: A systematic review. Echocardiography 2022; 39:310-329. [PMID: 34997638 DOI: 10.1111/echo.15285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 01/11/2023] Open
Abstract
We performed a systematic review of the literature on the assessment of subpulmonary and systemic right ventricular (RV) functional reserve during pharmacological and exercise stress in congenital heart patients and patients with pulmonary arterial hypertension (PAH). Literature search was conducted using PubMed, EMBASE, and MEDLINE from their inception up to August 2020. Of 913 records identified, 56 studies with a total of 1730 patients were included. Of the 56 studies, 23 assessed subpulmonary RV functional reserve in repaired tetralogy of Fallot patients, 19 assessed systemic RV reserve in patients with transposition of the great arteries (TGA) after atrial switch and those with congenitally corrected TGA, and 14 assessed subpulmonary RV research in patients with PAH. Pharmacological and exercise stress was used, respectively, in 22 and 34 studies. The main findings were (1) impairment of RV systolic and diastolic functional reserve, (2) associations between impaired functional reserve and worse baseline functional parameters, and (3) prognostic implications of RV systolic functional reserve on clinical outcomes in patients with volume and/or pressure-loaded subpulmonary and systemic right ventricles. Further studies are required to establish the incremental value of incorporating stress studies of RV systolic and diastolic function in the clinical management algorithm of congenital heart patients and patients with PAH.
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Affiliation(s)
- Sabine Cheng
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Vivian Wing-Yi Li
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Yiu-Fai Cheung
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
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Surkova E, Kovács A, Lakatos BK, Tokodi M, Fábián A, West C, Senior R, Li W. Contraction patterns of the systemic right ventricle: a three-dimensional echocardiography study. Eur Heart J Cardiovasc Imaging 2021; 23:1654-1662. [PMID: 34928339 DOI: 10.1093/ehjci/jeab272] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
AIMS To investigate contraction patterns of the systemic right ventricle (SRV) in patients with transposition of great arteries (TGA) post-atrial switch operation and with congenitally corrected transposition of great arteries (ccTGA). METHODS AND RESULTS Right ventricular (RV) volumes and ejection fraction (EF) were measured by three-dimensional echocardiography in 38 patients with the SRV (24 TGA and 14 ccTGA; mean age 45 ± 12 years, 63% male), and in 38 healthy volunteers. The RV contraction was decomposed along the longitudinal, radial, and anteroposterior directions providing longitudinal, radial, and anteroposterior EF (LEF, REF, and AEF, respectively) and their contributions to total right ventricular ejection fraction (LEFi, REFi, and AEFi, respectvely). SRV was significantly larger with lower systolic function compared with healthy controls. SRV EF and four-chamber longitudinal strain strongly correlated with B-type natriuretic peptide (BNP) level (Rho -0.73, P < 0.0001 and 0.70, P < 0.0001, respectively). In patients with TGA, anteroposterior component was significantly higher than longitudinal and radial components (AEF 17 ± 4.5% vs. REF 13 ± 4.9% vs. LEF 10 ± 3.3%, P < 0.0001; AEFi 0.48 ± 0.09 vs. REFi 0.38 ± 0.1 vs. LEFi 0.29 ± 0.08, P < 0.0001). In patients with ccTGA, there was no significant difference between three SRV components. AEFi was significantly higher in TGA subgroup compared with ccTGA (0.48 ± 0.09 vs. 0.36 ± 0.08, P = 0.0002). CONCLUSION Contraction patterns of the SRV are different in TGA and ccTGA. Anteroposterior component is dominant in TGA providing compensation for impaired longitudinal and radial components, while in ccTGA all components contribute equally to the total EF. SRV EF and longitudinal strain demonstrate strong correlation with BNP level and should be a part of routine echocardiographic assessment of the SRV.
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Affiliation(s)
- Elena Surkova
- Department of Echocardiography, Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, Chelsea, London SW3 6NP, UK
| | - Attila Kovács
- Echocardiography Core Laboratory, Heart and Vascular Center, Semmelweis University, 68, Varosmajor Str., Budapest H-1122, Hungary
| | - Bálint Károly Lakatos
- Echocardiography Core Laboratory, Heart and Vascular Center, Semmelweis University, 68, Varosmajor Str., Budapest H-1122, Hungary
| | - Márton Tokodi
- Echocardiography Core Laboratory, Heart and Vascular Center, Semmelweis University, 68, Varosmajor Str., Budapest H-1122, Hungary
| | - Alexandra Fábián
- Echocardiography Core Laboratory, Heart and Vascular Center, Semmelweis University, 68, Varosmajor Str., Budapest H-1122, Hungary
| | - Cathy West
- Department of Echocardiography, Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, Chelsea, London SW3 6NP, UK
| | - Roxy Senior
- Department of Echocardiography, Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, Chelsea, London SW3 6NP, UK.,National Heart Lung Institute, Imperial College of London, Guy Scadding Building, Dovehouse St, Chelsea, London SW3 6LY, UK
| | - Wei Li
- Department of Echocardiography, Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, Chelsea, London SW3 6NP, UK.,National Heart Lung Institute, Imperial College of London, Guy Scadding Building, Dovehouse St, Chelsea, London SW3 6LY, UK
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7
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Moya A, De Meester P, Troost E, Roggen L, Weidemann F, Moons P, Eyskens B, Claus P, Budts W, Van De Bruaene A. 15-Year follow-up of regional right and left ventricular function after the Senning operation: a Colour-Doppler myocardial imaging study. Acta Cardiol 2021; 76:689-696. [PMID: 32539571 DOI: 10.1080/00015385.2020.1770459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Despite right ventricular (RV) dysfunction being a major concern in Senning patients, long-term follow-up data is lacking. This study aimed (1) at evaluating regional (base-mid-apex) RV and left ventricular (LV) function using Colour-Doppler myocardial imaging over a 15-year follow-up period and (2) at comparing results with matched controls. METHODS For the longitudinal analysis (2004-2019), we compared systolic and diastolic function in 10 Senning patients. For the cross-sectional analysis, we compared the subaortic RV (sRV) of Senning patients with the RV and LV of matched controls and the subpulmonary LV (spLV) of Senning patients with the LV of matched controls. RESULTS The longitudinal analysis of sRV function showed a significant decrease in apical peak systolic strain (-17 ± 7% vs -12 ± 4%; p = 0.025) and apical peak systolic strain rate (-1.1 ± 0.3s-1 vs -0.8 ± 0.4s-1; p = 0.012). spLV function showed a significant decrease in peak systolic velocity (mid; p = 0.013 and apex; p = 0.011) and peak systolic strain rate (mid; p = 0.048). The cross-sectional analysis revealed significant lower values for basal, mid and apical peak systolic velocity, peak systolic strain rate, peak systolic strain of the sRV of Senning patients when compared to both LV and RV of matched controls (all p < 0.05). CONCLUSION Our study showed that systolic and diastolic sRV function did not change over a 15-year follow-up period, except in the apical region. There was a decline in spLV systolic function, which may be of clinical value. On the other hand, when compared to age- and gender-matched controls, the sRV of Senning patients exhibits significantly decreased measurements of longitudinal systolic function.
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Affiliation(s)
- Ana Moya
- Faculty of Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Pieter De Meester
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Els Troost
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Leen Roggen
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Benedicte Eyskens
- Division of Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Piet Claus
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Werner Budts
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Santens B, Helsen F, Van De Bruaene A, De Meester P, Budts AL, Troost E, Moons P, Claus P, Rega F, Bogaert J, Budts W. Adverse functional remodelling of the subpulmonary left ventricle in patients with a systemic right ventricle is associated with clinical outcome. Eur Heart J Cardiovasc Imaging 2021; 23:680-688. [PMID: 34059878 DOI: 10.1093/ehjci/jeab086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/21/2021] [Indexed: 01/03/2023] Open
Abstract
AIMS Early recognition of adverse remodelling is important since outcome is unfavorable once patients with a systemic right ventricle (sRV) become symptomatic. We aimed assessing prognostic markers linked to short-term clinical evolution in this population. METHODS AND RESULTS Thirty-three patients (76% male) with sRV (atrial switch repair for D-transposition of the great arteries and congenitally corrected transposition of the great arteries) underwent detailed phenotyping including exercise cardiac magnetic resonance and were followed over mean follow-up time of 3 years. Mean age was 40 ± 8 (range 26-57) years at latest follow-up. Adverse outcome was a composite of heart failure (HF) and tachyarrhythmia. Descriptive statistics and univariate cox regression analyses were performed. When compared with baseline: (i) most patients remained in New York Heart Association functional class I (76%), (ii) the degree of severity of the systemic atrioventricular valve regurgitation rose, and (iii) more electrical instability was documented at latest follow-up. Six (18%) of a total of 9 events were counted as first cardiovascular events (9% HF and 9% arrhythmia). NT-proBNP, oxygen pulse, left ventricle end-diastolic volume index (LVEDVi), and stroke volume index (SVi) of the subpulmonary left ventricle (LV) both in rest and at peak exercise were significantly associated with the first cardiovascular event. CONCLUSION NT-proBNP was by far the best prognostic marker for clinical outcome. Adverse remodelling with increase of LVEDVi and SVi of the subpulmonary LV at rest and during exercise were associated with worse clinical outcome. We theorize that remodelling of the subpulmonary ventricle might be an early sign of a failing sRV circulation.
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Affiliation(s)
- Béatrice Santens
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Frederik Helsen
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Anne-Laure Budts
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Els Troost
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Philip Moons
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Institute of Health and Care Sciences, University of Gothenburg, Gothenburg, Sweden.,Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Piet Claus
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium.,Department of Cardiothoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium.,Department of Imaging and Pathology, Catholic University Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital andStructural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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9
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Santens B, De Bosscher R, Budts W, Bogaert J. Exercise cardiac magnetic resonance imaging to assess dynamic right ventricular outflow tract obstruction in congenital heart disease: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 5:ytaa431. [PMID: 33644642 PMCID: PMC7898577 DOI: 10.1093/ehjcr/ytaa431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/15/2020] [Accepted: 10/26/2020] [Indexed: 11/18/2022]
Abstract
Background Right ventricular outflow tract obstruction in patients with congenital heart disease is usually assessed using echocardiographic peak instantaneous gradient at rest. Since right ventricular outflow tract obstruction may change during exercise (dynamic right ventricular outflow tract obstruction), we present a case emphasizing the potential use of exercise cardiac magnetic resonance imaging (CMR). Case summary We discuss a 15-year-old patient with repaired mid-ventricular sub-pulmonary stenosis type double-chambered right ventricle causing right ventricular outflow tract obstruction and symptoms on exertion. In this case, exercise CMR imaging provided additional information, allowing adequate surgical planning. Discussion The additional value of exercise CMR imaging in a case of right ventricular outflow tract obstruction was described. Although exercise cardiac magnetic resonance imaging did not show a significant increase in peak gradient across the right ventricular outflow tract obstruction, shifting and D-shaping of the interventricular septum with subsequent insufficient left ventricular filling (preload) was observed in the patient with recurrent double-chambered right ventricle. This case demonstrates how exercise CMR imaging can be helpful in the clinical decision beyond standard echocardiographic evaluation by providing additional evidence of adverse haemodynamics during exercise.
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Affiliation(s)
- Béatrice Santens
- Department of Cardiovascular Sciences, Congenital and Structural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Ruben De Bosscher
- Department of Cardiovascular Sciences, Catholic University Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Werner Budts
- Department of Cardiovascular Sciences, Congenital and Structural Cardiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.,Department of Imaging and Pathology, Catholic University Leuven, Herestraat 49, B-3000 Leuven, Belgium
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10
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Santens B, Van De Bruaene A, De Meester P, D'Alto M, Reddy S, Bernstein D, Koestenberger M, Hansmann G, Budts W. Diagnosis and treatment of right ventricular dysfunction in congenital heart disease. Cardiovasc Diagn Ther 2020; 10:1625-1645. [PMID: 33224777 DOI: 10.21037/cdt-20-370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Right ventricular (RV) function is important for clinical status and outcomes in children and adults with congenital heart disease (CHD). In the normal RV, longitudinal systolic function is the major contributor to global RV systolic function. A variety of factors contribute to RV failure including increased pressure- or volume-loading, electromechanical dyssynchrony, increased myocardial fibrosis, abnormal coronary perfusion, restricted filling capacity and adverse interactions between left ventricle (LV) and RV. We discuss the different imaging techniques both at rest and during exercise to define and detect RV failure. We identify the most important biomarkers for risk stratification in RV dysfunction, including abnormal NYHA class, decreased exercise capacity, low blood pressure, and increased levels of NTproBNP, troponin T, galectin-3 and growth differentiation factor 15. In adults with CHD (ACHD), fragmented QRS is independently associated with heart failure (HF) symptoms and impaired ventricular function. Furthermore, we discuss the different HF therapies in CHD but given the broad clinical spectrum of CHD, it is important to treat RV failure in a disease-specific manner and based on the specific alterations in hemodynamics. Here, we discuss how to detect and treat RV dysfunction in CHD in order to prevent or postpone RV failure.
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Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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11
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Craven TP, Tsao CW, La Gerche A, Simonetti OP, Greenwood JP. Exercise cardiovascular magnetic resonance: development, current utility and future applications. J Cardiovasc Magn Reson 2020; 22:65. [PMID: 32907587 PMCID: PMC7488086 DOI: 10.1186/s12968-020-00652-w] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 07/01/2020] [Indexed: 12/23/2022] Open
Abstract
Stress cardiac imaging is the current first line investigation for coronary artery disease diagnosis and decision making and an adjunctive tool in a range of non-ischaemic cardiovascular diseases. Exercise cardiovascular magnetic resonance (Ex-CMR) has developed over the past 25 years to combine the superior image qualities of CMR with the preferred method of exercise stress. Presently, numerous exercise methods exist, from performing stress on an adjacent CMR compatible treadmill to in-scanner exercise, most commonly on a supine cycle ergometer. Cardiac conditions studied by Ex-CMR are broad, commonly investigating ischaemic heart disease and congenital heart disease but extending to pulmonary hypertension and diabetic heart disease. This review presents an in-depth assessment of the various Ex-CMR stress methods and the varied pulse sequence approaches, including those specially designed for Ex-CMR. Current and future developments in image acquisition are highlighted, and will likely lead to a much greater clinical use of Ex-CMR across a range of cardiovascular conditions.
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Affiliation(s)
- Thomas P Craven
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
| | - Connie W Tsao
- Cardiovascular Division, Beth Israel Deaconess Medical Center, 330 Brookline Ave, RW-453, Boston, MA, 02215, USA
| | - Andre La Gerche
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Australia
- National Centre for Sports Cardiology, St Vincent's Hospital, Fitzroy, Australia
| | | | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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12
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Claessen G, La Gerche A, Van De Bruaene A, Claeys M, Willems R, Dymarkowski S, Bogaert J, Claus P, Budts W, Heidbuchel H, Gewillig M. Heart Rate Reserve in Fontan Patients: Chronotropic Incompetence or Hemodynamic Limitation? J Am Heart Assoc 2020; 8:e012008. [PMID: 31041880 PMCID: PMC6512107 DOI: 10.1161/jaha.119.012008] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Patients with a Fontan circulation achieve lower peak heart rates ( HR ) during exercise. Whether this impaired chronotropic response reflects pathology of the sinoatrial node or is a consequence of altered cardiac hemodynamics is uncertain. We evaluated the adequacy of HR acceleration throughout exercise relative to metabolic demand and cardiac output in patients with a Fontan circulation relative to healthy controls. Methods and Results Thirty subjects (20 healthy controls and 10 Fontan patients) underwent cardiac magnetic resonance imaging with simultaneous invasive pressure recording via a pulmonary and radial artery catheter during supine bicycle exercise to near maximal exertion. Adequacy of cardiac index, stroke volume, and HR reserve was assessed by determining the exercise-induced increase (∆) in cardiac index, stroke volume, and HR relative to the increase in oxygen consumption ( VO 2). HR reserve was lower in Fontan patients compared with controls (71±21 versus 92±15 bpm; P=0.001). In contrast, increases in HR relative to workload and VO 2 were higher than in controls. The change in cardiac index relative to the change in VO 2 (∆cardiac index/∆ VO 2) was similar between groups, but Fontan patients had increased ∆ HR /∆ VO 2 and reduced ∆ stroke volume/∆ VO 2 compared with controls. There was an early and marked reduction in stroke volume during exercise in Fontan patients corresponding with a plateau in cardiac output at a low peak HR . Conclusions In Fontan patients, the chronotropic response is appropriate relative to exercise intensity, implying normal sinoatrial function. However, premature reductions in ventricular filling and stroke volume cause an early plateau in cardiac output beyond which further increases in HR would be physiologically implausible. Thus, abnormal cardiac filling rather than sinoatrial node dysfunction explains the diminished HR reserve in Fontan patients.
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Affiliation(s)
- Guido Claessen
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium.,3 Baker IDI Heart and Diabetes Institute Melbourne Australia
| | - Andre La Gerche
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,3 Baker IDI Heart and Diabetes Institute Melbourne Australia
| | - Alexander Van De Bruaene
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium
| | - Mathias Claeys
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium
| | - Rik Willems
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium
| | - Steven Dymarkowski
- 2 University Hospitals Leuven Leuven Belgium.,4 Department of Imaging & Pathology KU Leuven Leuven Belgium
| | - Jan Bogaert
- 2 University Hospitals Leuven Leuven Belgium.,4 Department of Imaging & Pathology KU Leuven Leuven Belgium
| | - Piet Claus
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium
| | - Werner Budts
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium
| | | | - Marc Gewillig
- 1 Department of Cardiovascular Sciences KU Leuven Leuven Belgium.,2 University Hospitals Leuven Leuven Belgium
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13
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Gallego P, Oliver JM. Medical therapy for heart failure in adult congenital heart disease: does it work? Heart 2019; 106:154-162. [DOI: 10.1136/heartjnl-2019-314701] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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14
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Helsen F, Claus P, Van De Bruaene A, Claessen G, La Gerche A, De Meester P, Claeys M, Gabriels C, Petit T, Santens B, Troost E, Voigt JU, Bogaert J, Budts W. Advanced Imaging to Phenotype Patients With a Systemic Right Ventricle. J Am Heart Assoc 2019; 7:e009185. [PMID: 30371262 PMCID: PMC6474967 DOI: 10.1161/jaha.118.009185] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Reduced ventricular function and decreased exercise capacity are widespread in adults with complete transposition of the great arteries after atrial switch (TGA‐Mustard/Senning) and congenitally corrected TGA (ccTGA). Advanced imaging techniques may help to better phenotype these patients and evaluate exercise cardiac response. Methods and Results Thirty‐three adults with a systemic right ventricle (70% TGA‐Mustard/Senning, 37±9 years of age, 24% female, 94% New York Heart Association class I‐II) underwent echocardiogram, cardiopulmonary exercise testing, and cardiovascular magnetic resonance imaging at rest and during a 4‐stage free‐breathing bicycle test. They were compared with 12 healthy controls (39±10 years of age, 25% female, all New York Heart Association class I). TGA‐Mustard/Senning patients had a higher global circumferential strain (−15.8±3.6 versus −11.2±5.2%, P=0.008) when compared with ccTGA, whereas global longitudinal strain and systemic right ventricle contractility during exercise were similar in both groups. Septal extracellular volume (ECV) in ccTGA was significantly higher than in TGA‐Mustard/Senning (30.2±2.0 versus 27.1±2.7%, P=0.005). During exercise, TGA‐Mustard/Senning had a fall in end‐diastolic volume and stroke volume (11% and 8%, respectively; both P≤0.002), whereas ccTGA could increase their stroke volume in the same way as healthy controls. Because of a greater heart rate reserve in TGA‐Mustard/Senning (P for interaction=0.010), cardiac index and peak oxygen uptake were similar between both patient groups. Conclusions Caution should be exercised when evaluating pooled analyses of systemic right ventricle patients, given the differences in myocardial contraction pattern, septal extracellular volume, and the exercise response of TGA‐Mustard/Senning versus ccTGA patients. Longitudinal follow‐up will determine whether abnormal exercise cardiac response is a marker of earlier failure.
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Affiliation(s)
- Frederik Helsen
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Piet Claus
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium
| | - Alexander Van De Bruaene
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Guido Claessen
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - André La Gerche
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,3 Sports Cardiology and Cardiac Magnetic Resonance Imaging Lab Baker Heart and Diabetes Institute Melbourne Australia.,4 Department of Cardiology St Vincent's Hospital Melbourne Australia
| | - Pieter De Meester
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Mathias Claeys
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Charlien Gabriels
- 2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Thibault Petit
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Béatrice Santens
- 2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Els Troost
- 2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Jens-Uwe Voigt
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
| | - Jan Bogaert
- 5 Department of Imaging & Pathology KU Leuven-University of Leuven Belgium.,6 Department of Radiology University Hospitals Leuven Belgium
| | - Werner Budts
- 1 Department of Cardiovascular Sciences KU Leuven-University of Leuven Belgium.,2 Department of Cardiovascular Disease University Hospitals Leuven Belgium
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15
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Abstract
PURPOSE OF REVIEW We aim to review select literature pertaining to congenital heart disease (CHD)-induced right ventricular (RV) function and failure. RECENT FINDINGS We review recent findings pertaining to children and adults with repaired tetralogy of Fallot (rTOF), systemic RV and hypoplastic left heart syndrome (HLHS). We emphasize pathophysiological mechanisms contributing to RV dysfunction in these conditions, the risk factors for adverse outcomes and the continuing challenges in treating these patients. We discuss how recent pathology findings, as well as developments in imaging and computer modeling have broadened our understanding of the pathophysiology of these conditions. We further review developments in the molecular and cellular basis of RV failure; and in particular, the RV molecular response to stress in repaired tetralogy of Fallot (rTOF). We highlight some of the genetic complexities in HLHS and how these may influence the long-term outcomes in these patients. SUMMARY Recent literature has led to new understandings in the pathology, pathophysiology, risk factors for adverse outcomes, molecular and genetic basis for RV dysfunction and failure in CHD. Although these findings provide new therapeutic targets, the treatment of RV failure at this time remains limited.
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