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Avesani M, Jalal Z, Friedberg MK, Villemain O, Venet M, Di Salvo G, Thambo JB, Iriart X. Adverse remodelling in tetralogy of Fallot: From risk factors to imaging analysis and future perspectives. Hellenic J Cardiol 2024; 75:48-59. [PMID: 37495104 DOI: 10.1016/j.hjc.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/29/2023] [Accepted: 07/21/2023] [Indexed: 07/28/2023] Open
Abstract
Although contemporary outcomes of initial surgical repair of tetralogy of Fallot (TOF) are excellent, the survival of adult patients remains significantly lower than that of the normal population due to the high incidence of heart failure, ventricular arrhythmias, and sudden cardiac death. The underlying mechanisms are only partially understood but involve an adverse biventricular response, so-called remodelling, to key stressors such as right ventricular (RV) pressure-and/or volume-overload, myocardial fibrosis, and electro-mechanical dyssynchrony. In this review, we explore risk factors and mechanisms of biventricular remodelling, from histological to electro-mechanical aspects, and the role of imaging in their assessment. We discuss unsolved challenges and future directions to better understand and treat the long-term sequelae of this complex congenital heart disease.
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Affiliation(s)
- Martina Avesani
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France; Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Zakaria Jalal
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Mark K Friedberg
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Olivier Villemain
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Maeyls Venet
- Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Giovanni Di Salvo
- Paediatric Cardiology Unit, Department of Woman's and Child's Health, University-Hospital of Padova, University of Padua, Padua, Italy
| | - Jean-Benoît Thambo
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Xavier Iriart
- Paediatric and Congenital Cardiology Department, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France.
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Singh A, Muthiah T, Baidya DK. Anesthetic management of a parturient with uncorrected tetralogy of fallot and complicated blalock taussig shunt for cesarean section. J Anaesthesiol Clin Pharmacol 2023; 39:331-333. [PMID: 37564864 PMCID: PMC10410040 DOI: 10.4103/joacp.joacp_332_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 08/12/2021] [Indexed: 08/12/2023] Open
Affiliation(s)
- Anshul Singh
- Department of Anaesthesiology, University College of Medical Sciences and GTB Hospital, New Delhi, India
| | - Thilaka Muthiah
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Dalim Kumar Baidya
- Department of Anesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Faerber JA, Huang J, Zhang X, Song L, DeCost G, Mascio CE, Ravishankar C, O'Byrne ML, Naim MY, Kawut SM, Goldmuntz E, Mercer-Rosa L. Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach. Front Cardiovasc Med 2021; 8:685855. [PMID: 34368247 PMCID: PMC8339319 DOI: 10.3389/fcvm.2021.685855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jing Huang
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace DeCost
- School of Public Health, Brown University, Providence, RI, United States
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael L O'Byrne
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Maryam Y Naim
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven M Kawut
- Departments of Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Terol C, Kamphuis VP, Hazekamp MG, Blom NA, Ten Harkel ADJ. Left and Right Ventricular Impairment Shortly After Correction of Tetralogy of Fallot. Pediatr Cardiol 2020; 41:1042-1050. [PMID: 32363435 PMCID: PMC7314721 DOI: 10.1007/s00246-020-02355-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/23/2020] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Covadonga Terol
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Vivian P. Kamphuis
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Nico A. Blom
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,Division of Paediatric Cardiology, Department of Paediatrics, Academic Medical Centre, Amsterdam, The Netherlands
| | - Arend D. J. Ten Harkel
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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