Myocardial acceleration during isovolumic contraction as a new index of right ventricular contractile function and its relation to pulmonary regurgitation in patients after repair of tetralogy of Fallot

Abstract Introduction The detrimental impact of pulmonary regurgitation (PR) on right ventricular (RV) function of patients after repair of tetralogy of Fallot (TOF) is recognized. Although tricuspid annular isovolumic acceleration (IVA) is useful for the evaluation of RV function, it requires complicated measurement. Tricuspid annular plane systolic excursion (TAPSE) is measured easily and has also been validated as a marker of RV systolic function. Hypothesis We assessed the hypothesis that IVA has advantage to the stratification of the detrimental impact of PR on RV systolic function after TOF repair compared with TAPSE. Methods We prospectively examined patients after TOF repair. Patients <1 year after the repair, those with the history of sustained arrhythmia and those who required concomitant tricuspid and/or pulmonary valve surgery were excluded from the study. IVA was measured by dividing the myocardial velocity during isovolumic contraction by the time interval from the onset of the myocardial velocity during the isovolumic contraction to the time at the peak velocity of this wave. TAPSE was measured using M-mode echocardiography with the M-line passing through the lateral annulus of tricuspid valve in the apical 4-chamber plane. PR jets were evaluated in the parasternal short-axis plane. PR degree was assessed by the number of correspondence to the following conditions; 1) diastolic flow reversal in the main pulmonary artery, 2) diastolic flow reversal in the branch pulmonary arteries, 3) pressure half-time of PR signal <100 msec and 4) the ratio of the duration of the PR signal to the total duration of diastole <0.77. PR degree was graded from 0 to 4. Results Twenty-two patients were enrolled to the study. Age, female, period after the TOF repair and body height of the patients were 11±6 years, 55%, 9±5 years and 137±28 cm, respectively. In all the patients, IVA and TAPSE were 160±27 cm/sec2 and 12±2 mm, respectively. PR degrees were graded as 2, 3 and 4 in 4, 14 and 4 patients, respectively. By the Kruskal-Wallis test, only IVA showed a significant difference among the 3 PR degrees. Conclusion In conclusion, IVA can be a useful index for the stratification of RV function in patients after TOF repair with various degrees of PR.

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Mid- to long-term follow-up of pulmonary valve replacement with BioIntegral injectable valve

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezaa337 ◽

2020 ◽

Author(s):

Simone Ghiselli ◽

Cristina Carro ◽

Nicola Uricchio ◽

Giuseppe Annoni ◽

Stefano M Marianeschi

Keyword(s):

Cardiopulmonary Bypass ◽

Right Ventricular ◽

Tetralogy Of Fallot ◽

Valve Replacement ◽

Pulmonary Valve ◽

Pulmonary Stenosis ◽

Pulmonary Regurgitation ◽

Pulmonary Valve Replacement

Abstract OBJECTIVES Chronic pulmonary valve (PV) regurgitation is a common late sequela after repair of congenital heart diseases like tetralogy of Fallot or pulmonary stenosis, leading to right ventricular dilatation and failure and increased late morbidity and mortality. Timely reoperation may lead to a complete right ventricular recovery. An injectable PV allows pulmonary valve replacement, with or without cardiopulmonary bypass, under direct observation, thereby minimizing the impact of surgery on cardiac function. The aim of this study was to evaluate the feasibility and mid- to long-term clinical outcomes with this device. METHODS From April 2007 to October 2019, a total of 85 symptomatic patients with severe pulmonary regurgitation or pulmonary stenosis underwent pulmonary valve replacement with an injectable stented pulmonary prosthesis. Data were collected from the international proctoring registry. Mean patient age was 26.7 years. The underlying diagnosis was repaired tetralogy of Fallot in 69.4% patients; moderate or severe pulmonary regurgitation was present in 72.9%. All patients had echocardiographic scans before the operation and during the follow-up period. A total of 54.1% patients also had preoperative/postoperative cardiac magnetic resonance imaging (MRI) or catheterization; 25.9% had off-pump implants. In 53% patients, pulmonary valve replacement was associated with the repair of other cardiac defects. RESULTS Minor postoperative complications were observed in 10.8% patients. The overall mortality rate was 2.3%; mortality after valve replacement was linked to a severe cardiac insufficiency and it was not related to a prosthesis failure; 1 prosthesis was explanted from 1 patient because of endocarditis, and 6% of patients developed PV stenosis; minor complications occurred in 4.8%. The mean follow-up period was 4.8 years (2 months–12.7 years); 42% of the patients were followed for more than 5 years. Follow-up echocardiography and cardiac MRI showed a significant reduction in RV size and low gradients across the PV. CONCLUSIONS An injectable PV may be implanted without cardiopulmonary bypass and in a hybrid operating theatre with minimal surgical impact. The bioprosthesis, available up to large sizes, has a low profile, laminar flow and no risk of coronary artery compression. Incidence of endocarditis is rare. The lack of a suture ring permits the implant of a relatively larger prosthesis, thereby avoiding a right ventricular outflow tract obstruction. This device permits future percutaneous valve-in-valve procedures, if needed. Results concerning durability are encouraging, and mid- to long-term haemodynamic performance is excellent.

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Quantifying Pulmonary Regurgitation and Right Ventricular Function in Surgically Repaired Tetralogy of Fallot

Circulation Cardiovascular Imaging ◽

10.1161/circimaging.112.972588 ◽

2012 ◽

Vol 5 (5) ◽

pp. 637-643 ◽

Cited By ~ 71

Author(s):

Laura Mercer-Rosa ◽

Wei Yang ◽

Shelby Kutty ◽

Jack Rychik ◽

Mark Fogel ◽

...

Keyword(s):

Right Ventricular ◽

Ventricular Function ◽

Tetralogy Of Fallot ◽

Right Ventricular Function ◽

Pulmonary Regurgitation ◽

Repaired Tetralogy Of Fallot

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Altered biventricular hemodynamic forces in patients with repaired tetralogy of Fallot and right ventricular volume overload because of pulmonary regurgitation

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00330.2018 ◽

2018 ◽

Vol 315 (6) ◽

pp. H1691-H1702 ◽

Cited By ~ 5

Author(s):

Pia Sjöberg ◽

Johannes Töger ◽

Erik Hedström ◽

Per Arvidsson ◽

Einar Heiberg ◽

...

Keyword(s):

Blood Flow ◽

Right Ventricular ◽

Tetralogy Of Fallot ◽

Flow Direction ◽

Pulmonary Regurgitation ◽

Ventricular Volume ◽

Left Ventricular ◽

Hemodynamic Forces ◽

Control Subjects ◽

Repaired Tetralogy Of Fallot

Intracardiac hemodynamic forces have been proposed to influence remodeling and be a marker of ventricular dysfunction. We aimed to quantify the hemodynamic forces in patients with repaired tetralogy of Fallot (rToF) to further understand the pathophysiological mechanisms as this could be a potential marker for pulmonary valve replacement (PVR) in these patients. Patients with rToF and pulmonary regurgitation (PR) > 20% ( n = 18) and healthy control subjects ( n = 15) underwent MRI, including four-dimensional flow. A subset of patients ( n = 8) underwent PVR and MRI after surgery. Time-resolved hemodynamic forces were quantified using 4D-flow data and indexed to ventricular volume. Patients had higher systolic and diastolic left ventricular (LV) hemodynamic forces compared with control subjects in the lateral-septal/LV outflow tract ( P = 0.011 and P = 0.0031) and inferior-anterior ( P < 0.0001 and P < 0.0001) directions, which are forces not aligned with blood flow. Forces did not change after PVR. Patients had higher RV diastolic forces compared with control subjects in the diaphragm-right ventricular (RV) outflow tract (RVOT; P < 0.001) and apical-basal ( P = 0.0017) directions. After PVR, RV systolic forces in the diaphragm-RVOT direction decreased ( P = 0.039) to lower levels than in control subjects ( P = 0.0064). RV diastolic forces decreased in all directions ( P = 0.0078, P = 0.0078, and P = 0.039) but were still higher than in control subjects in the diaphragm-RVOT direction ( P = 0.046). In conclusion, patients with rToF and PR had LV hemodynamic forces less aligned with intraventricular blood flow compared with control subjects and higher diastolic RV forces along the regurgitant flow direction in the RVOT and that of tricuspid inflow. Remaining force differences in the LV and RV after PVR suggest that biventricular pumping does not normalize after surgery. NEW & NOTEWORTHY Biventricular hemodynamic forces in patients with repaired tetralogy of Fallot and pulmonary regurgitation were quantified for the first time. Left ventricular hemodynamic forces were less aligned to the main blood flow direction in patients compared with control subjects. Higher right ventricular forces were seen along the pulmonary regurgitant and tricuspid inflow directions. Differences in forces versus control subjects remain after pulmonary valve replacement, suggesting that altered biventricular pumping does not normalize after surgery.

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Ratio of Early Diastolic Tricuspid Inflow to Tricuspid Lateral Annulus Velocity Reflects Pulmonary Regurgitation Severity but Not Right Ventricular Diastolic Function in Children With Repaired Tetralogy of Fallot

Pediatric Cardiology ◽

10.1007/s00246-012-0612-1 ◽

2012 ◽

Vol 34 (5) ◽

pp. 1112-1117 ◽

Cited By ~ 5

Author(s):

Yasunobu Hayabuchi ◽

Miho Sakata ◽

Tatsuya Ohnishi ◽

Miki Inoue ◽

Shoji Kagami

Keyword(s):

Right Ventricular ◽

Diastolic Function ◽

Tetralogy Of Fallot ◽

Pulmonary Regurgitation ◽

Ventricular Diastolic Function ◽

Repaired Tetralogy Of Fallot ◽

Right Ventricular Diastolic Function

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Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez245 ◽

2019 ◽

Vol 21 (8) ◽

pp. 906-913 ◽

Cited By ~ 1

Author(s):

Imran Rashid ◽

Adil Mahmood ◽

Tevfik F Ismail ◽

Shamus O’Meagher ◽

Shelby Kutty ◽

...

Keyword(s):

Right Ventricular ◽

Tetralogy Of Fallot ◽

Exercise Capacity ◽

Multivariable Analysis ◽

Cardiopulmonary Exercise Testing ◽

Pulmonary Regurgitation ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Peak Vo2 ◽

Repaired Tetralogy Of Fallot

Abstract Aims The optimal timing for pulmonary valve replacement in asymptomatic patients with repaired Tetralogy of Fallot (rTOF) and pulmonary regurgitation remains uncertain but is often guided by increases in right ventricular (RV) end-diastolic volume. As cardiopulmonary exercise testing (CPET) performance is a strong prognostic indicator, we assessed which cardiovascular magnetic resonance (CMR) parameters correlate with reductions in exercise capacity to potentially improve identification of high-risk patients. Methods and results In all, 163 patients with rTOF (mean age 24.5 ± 10.2 years) who had previously undergone CMR and standardized CPET protocols were included. The indexed right and left ventricular end-diastolic volumes (RVEDVi, LVEDVi), right and left ventricular ejection fractions (RVEF, LVEF), indexed RV stroke volume (RVSVi), and pulmonary regurgitant fraction (PRF) were quantified by CMR and correlated with CPET-determined peak oxygen consumption (VO2) or peak work. On univariable analysis, there was no significant correlation between RVEDVi and PRF with peak VO2 or peak work (% Jones-predicted). In contrast, RVEF and RVSVi had significant correlations with both peak VO2 and peak work that remained significant on multivariable analysis. For a previously established prognostic peak VO2 threshold of <27 mL/kg/min, receiver-operating characteristic curve analysis demonstrated a Harrell’s c of 0.70 for RVEF (95% confidence interval 0.61–0.79) with a sensitivity of 88% for RVEF <40%. Conclusion In rTOF, CMR indices of RV systolic function are better predictors of CPET performance than RV size. An RVEF <40% may be useful to identify prognostically significant reductions in exercise capacity in patients with varying degrees of RV dilatation.

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