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Leonardi B, Cifra B. The Role of Cardiopulmonary Testing to Risk Stratify Tetralogy of Fallot Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:314-321. [PMID: 38161674 PMCID: PMC10755826 DOI: 10.1016/j.cjcpc.2023.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/13/2023] [Indexed: 01/03/2024]
Abstract
Neonatal repair has completely changed the clinical history of patients with tetralogy of Fallot (ToF); however, these patients carry a significant risk of severe arrhythmias and sudden cardiac death in the long term. The exact mechanism for late sudden cardiac death is multifactorial and still not well defined, and the risk stratification for primary prophylaxis in these patients remains challenging. Cardiopulmonary exercise testing (CPET) is a well-established and safe method to assess cardiopulmonary function in children and adults with congenital heart disease. Several parameters obtained with CPET have been identified as potential prognostic of major adverse cardiovascular events in congenital heart disease. CPET is routinely used to assess functional capacity also in patients with ToF, and there is some evidence showing its usefulness in predicting the cardiac adverse events in patients with repaired ToF. Current guidelines recognize the importance of CPET in the evaluation and management of patients with ToF, but there is no clear consensus on which the CPET parameter or level of exercise intolerance, as measured by CPET, is truly predictive of an increased risk of arrhythmia and major adverse cardiovascular events in this population. Therefore, the aim of this narrative review is to describe the current evidence on the potential use of CPET in the risk stratification of patients with repaired ToF.
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Affiliation(s)
- Benedetta Leonardi
- Department of Pediatric Cardiology, Cardiac Surgery and Heart Lung Transplantation, Bambino Gesù Hospital, IRCCS, Rome, Italy
| | - Barbara Cifra
- Division of Cardiology, Labatt Family Heart Centre, the Hospital for Sick Children, Toronto, Ontario, Canada
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Kim SJ, Li MH, Noh CI, Kim SH, Lee CH, Yoon JK. Impact of Pulmonary Arterial Elastance on Right Ventricular Mechanics and Exercise Capacity in Repaired Tetralogy of Fallot. Korean Circ J 2023; 53:406-417. [PMID: 37271746 DOI: 10.4070/kcj.2022.0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pathophysiological changes of right ventricle (RV) after repair of tetralogy of Fallot (TOF) are coupled with a highly compliant low-pressure pulmonary artery (PA) system. This study aimed to determine whether pulmonary vascular function was associated with RV parameters and exercise capacity, and its impact on RV remodeling after pulmonary valve replacement. METHODS In a total of 48 patients over 18 years of age with repaired TOF, pulmonary arterial elastance (Ea), RV volume data, and RV-PA coupling ratio were calculated and analyzed in relation to exercise capacity. RESULTS Patients with a low Ea showed a more severe pulmonary regurgitation volume index, greater RV end-diastolic volume index, and greater effective RV stroke volume (p=0.039, p=0.013, and p=0.011, respectively). Patients with a high Ea had lower exercise capacity than those with a low Ea (peak oxygen consumption [peak VO2] rate: 25.8±7.7 vs. 34.3±5.5 mL/kg/min, respectively, p=0.003), while peak VO2 was inversely correlated with Ea and mean PA pressure (p=0.004 and p=0.004, respectively). In the univariate analysis, a higher preoperative RV end-diastolic volume index and RV end-systolic volume index, left ventricular end-systolic volume index, and higher RV-PA coupling ratio were risk factors for suboptimal outcomes. Preoperative RV volume and RV-PA coupling ratio reflecting the adaptive PA system response are important factors in optimal postoperative results. CONCLUSIONS We found that PA vascular dysfunction, presenting as elevated Ea in TOF, may contribute to exercise intolerance. However, Ea was inversely correlated with pulmonary regurgitation (PR) severity, which may prevent PR, RV dilatation, and left ventricular dilatation in the absence of significant pulmonary stenosis.
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Affiliation(s)
- Soo-Jin Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Mei Hua Li
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
- The Sixth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chung Il Noh
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea.
| | - Seong-Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Ja-Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
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Cardiopulmonary Exercise Testing in Repaired Tetralogy of Fallot: Multiparametric Overview and Correlation with Cardiac Magnetic Resonance and Physical Activity Level. J Cardiovasc Dev Dis 2022; 9:jcdd9010026. [PMID: 35050237 PMCID: PMC8778451 DOI: 10.3390/jcdd9010026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with repaired Tetralogy of Fallot (rToF) typically report having preserved subjective exercise tolerance. Chronic pulmonary regurgitation (PR) with varying degrees of right ventricular (RV) dilation as assessed by cardiac magnetic resonance imaging (MRI) is prevalent in rToF and may contribute to clinical compromise. Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity, and the International Physical Activity Questionnaire (IPAQ) can provide additional data on physical activity (PA) achieved. Our aim was to assess the association between CPET values, IPAQ measures, and MRI parameters. All rToF patients who had both an MRI and CPET performed within one year between March 2019 and June 2021 were selected. Clinical data were extracted from electronic records (including demographic, surgical history, New York Heart Association (NYHA) functional class, QRS duration, arrhythmia, MRI parameters, and CPET data). PA level, based on the IPAQ, was assessed at the time of CPET. Eighty-four patients (22.8 ± 8.4 years) showed a reduction in exercise capacity (median peak VO2 30 mL/kg/min (range 25–33); median percent predicted peak VO2 68% (range 61–78)). Peak VO2, correlated with biventricular stroke volumes (RVSV: β = 6.11 (95%CI, 2.38 to 9.85), p = 0.002; LVSV: β = 15.69 (95% CI 10.16 to 21.21), p < 0.0001) and LVEDVi (β = 8.74 (95%CI, 0.66 to 16.83), p = 0.04) on multivariate analysis adjusted for age, gender, and PA level. Other parameters which correlated with stroke volumes included oxygen uptake efficiency slope (OUES) (RVSV: β = 6.88 (95%CI, 1.93 to 11.84), p = 0.008; LVSV: β = 17.86 (95% CI 10.31 to 25.42), p < 0.0001) and peak O2 pulse (RVSV: β = 0.03 (95%CI, 0.01 to 0.05), p = 0.007; LVSV: β = 0.08 (95% CI 0.05 to 0.11), p < 0.0001). On multivariate analysis adjusted for age and gender, PA level correlated significantly with peak VO2/kg (β = 0.02, 95% CI 0.003 to 0.04; p = 0.019). We observed a reduction in objective exercise tolerance in rToF patients. Biventricular stroke volumes and LVEDVi were associated with peak VO2 irrespective of RV size. OUES and peak O2 pulse were also associated with biventricular stroke volumes. While PA level was associated with peak VO2, the incremental value of this parameter should be the focus of future studies.
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Better preoperative exercise function is associated with shorter hospital stay after paediatric pulmonary valve replacement or conduit revision. Cardiol Young 2021; 31:1636-1643. [PMID: 33658103 DOI: 10.1017/s1047951121000743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Exercise capacity is a modifiable factor in patients with CHD that has been related to surgical outcomes in adults. We hypothesised that this was true for children undergoing surgical pulmonary valve replacement; therefore, the relationship of preoperative percent predicted peak oxygen consumption to surgical outcomes as measured by total hospital length of stay was explored. METHODS Single centre retrospective cohort study of patients aged 8-18 years who underwent surgical pulmonary valve replacement. The primary predictor was preoperative percent predicted peak oxygen consumption, and primary outcome was total hospital length of stay. Clinical, imaging, and cardiopulmonary exercise test data were reviewed and compared to total hospital length of stay. Cox proportional hazards regression was used to examine the association between total hospital length of stay and percent predicted peak oxygen consumption. RESULTS Three-hundred and seventy patients undergoing pulmonary valve replacement/conduit change between 2003 and 2017 at Boston Children's Hospital were identified. Ninety had preoperative cardiopulmonary exercise tests within 6 months of surgery. Exclusion for inadequate exercise data (n = 3) and imaging data (n = 1) left 86 patients for review. Patients with percent predicted peak oxygen consumption ≥ 70% (n = 46, 53%) had shorter total hospital length of stay (4.4 days) than the 40 with percent predicted peak oxygen consumption <70% (5.4 days, p = 0.007). Median percent predicted peak oxygen consumption increased over sequential surgical eras (p < 0.001), but total hospital length of stay did not correlate with surgical era, preoperative left ventricular function, or preoperative right ventricular dilation. CONCLUSION Children undergoing surgical pulmonary valve replacement with better preoperative exercise capacity had shorter total hospital length of stay. Exercise capacity is a potentially modifiable factor prior to and after pulmonary valve replacement. Until more patients systematically undergo cardiopulmonary exercise tests, the full impact of optimisation of exercise capacity will not be known.
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Loke YH, Capuano F, Cleveland V, Mandell JG, Balaras E, Olivieri LJ. Moving beyond size: vorticity and energy loss are correlated with right ventricular dysfunction and exercise intolerance in repaired Tetralogy of Fallot. J Cardiovasc Magn Reson 2021; 23:98. [PMID: 34412634 PMCID: PMC8377822 DOI: 10.1186/s12968-021-00789-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/28/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The global effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dilation and dysfunction in repaired Tetralogy of Fallot (rTOF) patients is well studied by cardiovascular magnetic resonance (CMR). However, the links between PR in the RV outflow tract (RVOT), RV dysfunction and exercise intolerance are not clarified by conventional measurements. Not all patients with RV dilation share the same intracardiac flow characteristics, now measurable by time resolved three-dimensional phase contrast imaging (4D flow). In our study, we quantified regional vorticity and energy loss in rTOF patients and correlated these parameters with RV dysfunction and exercise capacity. METHODS rTOF patients with 4D flow datasets were retrospectively analyzed, including those with transannular/infundibular repair and conduit repair. Normal controls and RV dilation patients with atrial-level shunts (Qp:Qs > 1.2:1) were included for comparison. 4D flow was post-processed using IT Flow (Cardioflow, Japan). Systolic/diastolic vorticity (ω, 1/s) and viscous energy loss (VEL, mW) in the RVOT and RV inflow were measured. To characterize the relative influence of diastolic vorticity in the two regions, an RV Diastolic Vorticity Quotient (ωRVOT-Diastole/ωRV Inflow-Diastole, RV-DVQ) was calculated. Additionally, RVOT Vorticity Quotient (ωRVOT-Diastole/ωRVOT-Systole, RVOT-VQ) and RVOT Energy Quotient (VELRVOT-Diastole/VELRVOT-Systole, RVOT-EQ) was calculated. In rTOF, measurements were correlated against conventional CMR and exercise stress test results. RESULTS 58 rTOF patients, 28 RV dilation patients and 12 controls were included. RV-DVQ, RVOT-VQ, and RVOT-EQ were highest in rTOF patients with severe PR compared to rTOF patients with non-severe PR, RV dilation and controls (p < 0.001). RV-DVQ positively correlated with RV end-diastolic volume (0.683, p < 0.001), PR fraction (0.774, p < 0.001) and negatively with RV ejection fraction (- 0.521, p = 0.003). Both RVOT-VQ, RVOT-EQ negatively correlated with VO2-max (- 0.587, p = 0.008 and - 0.617, p = 0.005) and % predicted VO2-max (- 0.678, p = 0.016 and - 0.690, p = 0.001). CONCLUSIONS In rTOF patients, vorticity and energy loss dominate the RVOT compared to tricuspid inflow, correlating with RV dysfunction and exercise intolerance. These 4D flow-based measurements may be sensitive biomarkers to guide surgical management of rTOF patients.
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Affiliation(s)
- Yue-Hin Loke
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA.
| | - Francesco Capuano
- Department of Mechanics, Mathematics and Management, Polytechnic University of Bari, Bari, Italy
| | - Vincent Cleveland
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Jason G Mandell
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA
| | - Elias Balaras
- Department of Mechanical and Aerospace Engineering, George Washington University, Washington, DC, 20052, USA
| | - Laura J Olivieri
- Division of Cardiology, Children's National Medical Center, 111 Michigan Ave NW, W3-200, Washington, DC, 20010, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC, 20010, USA
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Physiologic effects and functional outcome after treatment of dysfunctional right ventricular outflow tract in congenital heart disease using a two-stage intervention. Int J Cardiol 2020; 321:69-74. [PMID: 32593726 DOI: 10.1016/j.ijcard.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 04/15/2020] [Accepted: 06/14/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pathophysiological differences in relief of pulmonary stenosis (PS) as opposed to pulmonary regurgitation (PR) by percutaneous pulmonary valve implantation (PPVI) remain elusive, but might impact current assessment of procedural success and ultimately indications. METHODS Invasive pressure measurements, cardiac magnetic resonance imaging and cardiopulmonary exercise testing were performed before pre-stenting (BMS), after BMS and after PPVI in patients with either PS or PR. RESULTS In PS (n = 14), BMS reduced the right ventricular (RV) to systemic pressure ratio (0.8 ± 0.2 vs. 0.4 ± 0.1%; p < .01), improved RF EF (53 ± 14 vs. 59 ± 12%; p = .01) but introduced free PR (PR fraction post 39 ± 12%; p < .01) with no changes in effective RV stroke volume (SV). PPVI eliminated PR (PR fraction 5 ± 3%; p < .01) and improved effective RV SV (p < .01) with no changes in RV EF (p = .47). Peak VO2 improved significantly after BMS, with no changes following PPVI (26 ± 9 vs. 30 ± 11 vs. 31 ± 10 ml/kg*min). In PR (n = 14), BMS exaggerated PR (PR fraction post 47 ± 10) with reduction in effective RV SV (pre 43 ± 9 vs. post 38 ± 8 ml/m2; p = .01), which improved after PPVI (post PPVI 49 ± 9 ml/m2; p < .01), secondary to elimination of PR (PR fraction 5 ± 4%; p < .01). RV EF (pre 53 ± 11 vs. post 53 ± 9 vs. post PPVI 50 ± 9%) and Peak VO2 (pre 22 ± 7 vs. post 21 ± 7 vs. post PPVI 23 ± 7 ml/kg*min) remained unchanged. CONCLUSIONS Exercise capacity in patients with right ventricular outflow tract dysfunction is primarily afterload-dependent.
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The impact of pulmonary regurgitation on right ventricular size and function in patients with repaired tetralogy of Fallot and additional haemodynamic abnormalities. Pol J Radiol 2020; 85:e607-e612. [PMID: 33376562 PMCID: PMC7757502 DOI: 10.5114/pjr.2020.101058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/25/2020] [Indexed: 12/04/2022] Open
Abstract
Purpose Right ventricular (RV) outflow tract obstruction (RVOTO) was demonstrated to be protective against RV dilatation in patients with repaired tetralogy of Fallot and chronic pulmonary regurgitation (PR). We hypothesised that the presence of additional haemodynamic abnormalities (more than mild tricuspid regurgitation, residual ventricular septal defect) reduces this protective association. Accordingly, we aimed to assess the impact of PR on RV size and function in this population. Material and methods Consecutive patients with additional haemodynamic abnormalities after tetralogy of Fallot (TOF) repair, who had undergone cardiovascular magnetic resonance, were included. Results Out of 90 patients studied, 18 individuals (mean age 32.5 ± 10.7 years, 72.2% males) met the inclusion criteria. There were no differences in RV volumes and ejection fraction between patients with and without RVOTO. Neither PR fraction (PRF) nor PR volume (PRV) correlated with RV end-diastolic volume (r = 0.36; p = 0.15 and r = 0.37; p = 0.14, respectively, for PRF and PRV) or RV end-systolic volume (r = 0.2; p = 0.42 and r = 0.19; p = 0.45, respectively, for PRF and PRV). Similarly, no significant correlations were observed between PRF or PRV and RV ejection fraction (r = –0.04; p = 0.87 and r = –0.03; p = 0.9, respectively). Conclusions Additional haemodynamic abnormalities are associated with the abolition of the protective effect of RVOTO on RV size. There was no significant relationship between measures of PR and RV volumes in patients after TOF repair with concomitant haemodynamic abnormalities. These abnormalities acted as confounding factors in the assessment of the impact of pulmonary regurgitation on RV size and function.
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Cardiopulmonary Exercise Test (CPET) in patients with repaired Tetralogy of Fallot (rTOF); A systematic review. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Guirgis L, Khraiche D, Ladouceur M, Iserin L, Bonnet D, Legendre A. Cardiac performance assessment during cardiopulmonary exercise test can improve the management of children with repaired congenital heart disease. Int J Cardiol 2020; 300:121-126. [DOI: 10.1016/j.ijcard.2019.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/03/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
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Lu JC, Balasubramanian S, Yu S, Mahani MG, Agarwal PP, Dorfman AL. Reproducibility and Agreement of Tissue Tracking versus Feature Tracking for Strain Measurement on Cardiac MR Images in Patients with Repaired Tetralogy of Fallot. Radiol Cardiothorac Imaging 2019; 1:e180005. [PMID: 33778498 PMCID: PMC7977742 DOI: 10.1148/ryct.2019180005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 06/12/2023]
Abstract
PURPOSE To evaluate differences in strain measurements by using tissue-tracking (TT) and feature-tracking (FT) software on cardiovascular MR images in patients with repaired tetralogy of Fallot (TOF). MATERIALS AND METHODS In this retrospective cross-sectional study of 25 patients with repaired TOF (median age, 33.1 years; interquartile range, 25.3-38.3 years) from 2008 through 2014, left ventricular (LV) and right ventricular (RV) global circumferential and longitudinal strain were measured from cardiac MR images by using TT and FT software. Time to process was measured from opening the study to acceptance of contours. Intra- and interobserver reproducibility were evaluated with Bland-Altman analysis, coefficient of variation, and intraclass correlation coefficient. RESULTS Time to process was slightly longer for TT (10.2 minutes ± 3.1 [standard deviation] vs 9.0 minutes ± 1.7, P = .04). Fewer patients required contour revision with TT than with FT. Both TT and FT measurements had similar moderate-to-strong correlations with LV and RV ejection fractions; correlation of RV longitudinal strain with RV ejection fraction did not reach significance by using either method. With the exception of LV circumferential strain, strain measurements were lower with FT relative to TT. Intra- and interobserver reproducibility were lower with FT for longitudinal strain measurements. CONCLUSION TT and FT have systematic differences in strain values and reproducibility, particularly for longitudinal strain. Software-specific normative data are necessary, as are studies to evaluate correlation with clinical outcomes for each modality.© RSNA, 2019.
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Gnanappa GK, Celermajer DS, Zhu D, Puranik R, Ayer J. Severe right ventricular dilatation after repair of Tetralogy of Fallot is associated with increased left ventricular preload and stroke volume. Eur Heart J Cardiovasc Imaging 2019; 20:1020-1026. [DOI: 10.1093/ehjci/jez035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/11/2018] [Accepted: 02/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Pulmonary regurgitation (PR) and right ventricular (RV) dilatation are common in repaired tetralogy of Fallot (rTOF). Left ventricular (LV) dysfunction is an important risk factor in rTOF. The effect of PR/RV dilatation on LV performance and RV-LV interactions in rTOF are incompletely understood. We examined LV responses and exercise capacity in rTOF, both before and after pulmonary valve replacement (PVR).
Methods and results
Cardiac magnetic resonance imaging scans in 126 rTOF patients (age 17.3 ± 7.6 years) were analysed, comparing subjects with indexed RV end-diastolic volume (RVEDVi) <170 mL/m2 (mild/moderate dilatation, n = 95) and RVEDVi ≥170 mL/m2 (severe dilatation, n = 31). Indexed PR volume (PRVi), RV end-systolic (RVESVi), RV end-diastolic (RVEDVi), RV stroke volume (RVSVi), net pulmonary forward flow (NPFFi), LV end-diastolic (LVEDVi), LV end-systolic (LVESVi), LV stroke volume (LVSVi), RV and LV ejection fraction (EF), and diastolic septal curvature were obtained. Peak aerobic capacity (VO2 max) was measured. In a subset (n = 30), measures were obtained pre-and-post surgical PVR. Compared to those with mild/moderate RV dilatation, patients with severe RV dilation had greater PRVi (38 ± 12 vs. 24 ± 9 mL/m2, P < 0.0001), NPFFi (53 ± 9 vs. 44 ± 11 mL/m2, P < 0.0001), LVEDVi (87 ± 14 vs. 73 ± 13 mL/m2, P < 0.0001), LVESVi (39 ± 12 vs. 30 ± 8 mL/m2, P < 0.0001), and LVSVi (48 ± 7 vs. 43 ± 8 mL/m2, P = 0.002) but lower RV ejection fraction (46 ± 8 vs. 53 ± 7%, P < 0.0001). Septal curvature and VO2 max were similar in both groups. After PVR, there was no change in LVEDVi, LVSVi, septal curvature, or VO2 max.
Conclusions
Chronic PR with severe RV dilatation is associated with increased NPFFi, LVEDVi, and LVSVi. This may potentially explain preserved exercise capacity in rTOF with severe PR and RV dilatation.
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Affiliation(s)
- Ganesh Kumar Gnanappa
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
| | - David S Celermajer
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Danyi Zhu
- School of Electrical and Information Technology, University of Sydney, Maze Crescent, Darlington, New South Wales 2006, Australia
| | - Rajesh Puranik
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
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Dłużniewska N, Podolec P, Miszalski-Jamka T, Krupiński M, Banyś P, Urbańczyk M, Suder B, Kopeć G, Olszowska M, Tomkiewicz-Pająk L. Effect of ventricular function and volumes on exercise capacity in adults with repaired Tetralogy of Fallot. Indian Heart J 2017; 70:87-92. [PMID: 29455794 PMCID: PMC5902910 DOI: 10.1016/j.ihj.2017.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 11/28/2022] Open
Abstract
Objectives Investigate the effects of left and right ventricular function and severity of pulmonary valve regurgitation, quantified by cardiac magnetic resonance (CMR), on exercise tolerance in adult patients who underwent ToF repair at a young age. Methods This is a retrospective cohort study of 52 patients after ToF surgery and 33 age- and sex-matched healthy volunteers. CMR and cardiopulmonary exercise testing (CPET) were performed on all patients; CPET was performed on control subjects. Results The main finding of CPET was a severe decrease in oxygen uptake at peak exercise VO2peak in TOF patients. The patients were characterized also by lower pulse O2peak and heart rate at peak exercise. Ejection fraction of the right and left ventricles was correlated (r = 0,32; p = 0,03). Left ventricle ejection fraction was negatively correlated with right ventricular volumes (r = −0,34; p = 0,01) and right ventricular mass (r = −046; p < 0,00). Right ventricular mass was positively correlated with left ventricular variables (left ventricle end diastolic volume, r = 0,43; p = 0,002; left ventricle end systolic volume, r = 0,54; p < 0,00) as was VO2peak: LVEDV (r = 0,38; p = 0,01); LVESV (r = 0,33; p = 0,03) and LV mass (r = 0,42; p = 0,006). Conclusion Exercise intolerance in adults with repaired ToF is markedly depressed. The decreased exercise capacity is correlated with impaired RV function and may be associated also with LV dysfunction, which suggests right-to-left ventricular interaction.
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Affiliation(s)
- Natalia Dłużniewska
- Department of Cardiac and Vascular Disease, Jagiellonian Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland.
| | - Piotr Podolec
- Department of Cardiac and Vascular Disease, Jagiellonian Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Tomasz Miszalski-Jamka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland; Jagiellonian Centre for Experimental Therapeutic (JCET), Jagiellonian University, Krakow, Poland
| | - Maciej Krupiński
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - Paweł Banyś
- Magnetic Resonance Imaging Laboratory, John Paul II Hospital, Krakow, Poland
| | | | - Bogdan Suder
- Department of Cardiovascular Surgery and Transplantation, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Grzegorz Kopeć
- Department of Cardiac and Vascular Disease, Jagiellonian Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Maria Olszowska
- Department of Cardiac and Vascular Disease, Jagiellonian Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Disease, Jagiellonian Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
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Abstract
Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. As a result of the surgical strategies employed at the time of initial repair, chronic pulmonary regurgitation (PR) is prevalent in this population. Despite sustained research efforts, patient selection and timing of pulmonary valve replacement (PVR) to address PR in young asymptomatic patients with repaired tetralogy of Fallot (rToF) remain a fundamental but as yet unanswered question in the field of congenital heart disease. The ability of the heart to compensate for the chronic volume overload imposed by PR is critical in the evaluation of the risks and benefits of PVR. The difficulty in clarifying the functional impact of PR on the cardiovascular capacity may be in part responsible for the uncertainty surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET) may be used to assess abnormal cardiovascular response to increased physiologic demands. However, its use as a tool for risk stratification in asymptomatic adolescents and young adults with rToF is still ill-defined. In this paper, we review the role of CPET as a potentially valuable adjunct to current risk stratification strategies with a focus on asymptomatic rToF adolescents and young adults being considered for PVR. The role of maximal and submaximal exercise measurements to identify young patients with a decreased or borderline low peak VO2 resulting from impaired ventricular function is explored. Current knowledge gaps and research perspectives are highlighted.
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Luo S, Li J, Yang D, Zhou Y, An Q, Chen Y. Right ventricular outflow tract systolic function correlates with exercise capacity in patients with severe right ventricle dilatation after repair of tetralogy of Fallot. Interact Cardiovasc Thorac Surg 2017; 24:755-761. [DOI: 10.1093/icvts/ivw424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/29/2016] [Indexed: 11/14/2022] Open
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de Melo BL, Vieira SS, Antônio EL, Dos Santos LFN, Portes LA, Feliciano RS, de Oliveira HA, Silva JA, de Carvalho PDTC, Tucci PJF, Serra AJ. Exercise Training Attenuates Right Ventricular Remodeling in Rats with Pulmonary Arterial Stenosis. Front Physiol 2016; 7:541. [PMID: 27994552 PMCID: PMC5136544 DOI: 10.3389/fphys.2016.00541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/27/2016] [Indexed: 12/04/2022] Open
Abstract
Introduction: Pulmonary arterial stenosis (PAS) is a congenital defect that causes outflow tract obstruction of the right ventricle (RV). Currently, negative issues are reported in the PAS management: not all patients may be eligible to surgeries; there is often the need for another surgery during passage to adulthood; patients with mild stenosis may have later cardiac adverse repercussions. Thus, the search for approaches to counteract the long-term PAS effects showed to be a current target. At the study herein, we evaluated the cardioprotective role of exercise training in rats submitted to PAS for 9 weeks. Methods and Results: Exercise resulted in improved physical fitness and systolic RV function. Exercise also blunted concentric cavity changes, diastolic dysfunction, and fibrosis induced by PAS. Exercise additional benefits were also reported in a pro-survival signal, in which there were increased Akt1 activity and normalized myocardial apoptosis. These findings were accompanied by microRNA-1 downregulation and microRNA-21 upregulation. Moreover, exercise was associated with a higher myocardial abundance of the sarcomeric protein α-MHC and proteins that modulate calcium handling—ryanodine receptor and Serca 2, supporting the potential role of exercise in improving myocardial performance. Conclusion: Our results represent the first demonstration that exercise can attenuate the RV remodeling in an experimental PAS. The cardioprotective effects were associated with positive modulation of RV function, survival signaling pathway, apoptosis, and proteins involved in the regulation of myocardial contractility.
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Affiliation(s)
- Brunno Lemes de Melo
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | - Stella S Vieira
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | - Ednei L Antônio
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | - Luís F N Dos Santos
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | - Leslie A Portes
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | | | | | - José A Silva
- Biophotonic Laboratory, Nove de Julho University São Paulo, Brazil
| | | | - Paulo J F Tucci
- Cardiac Physiology Laboratory, Federal University of São Paulo São Paulo, Brazil
| | - Andrey J Serra
- Cardiac Physiology Laboratory, Federal University of São PauloSão Paulo, Brazil; Biophotonic Laboratory, Nove de Julho UniversitySão Paulo, Brazil
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Usefulness of maximal oxygen pulse in timing of pulmonary valve replacement in patients with isolated pulmonary regurgitation. Cardiol Young 2016; 26:1310-8. [PMID: 26692200 DOI: 10.1017/s1047951115002504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Patients with pulmonary regurgitation after tetralogy of Fallot repair have impaired aerobic capacity; one of the reasons is the decreasing global ventricular performance at exercise, reflected by decreasing peak oxygen pulse. The aims of our study were to evaluate the impact of pulmonary valve replacement on peak oxygen pulse in a population with pure pulmonary regurgitation and with different degrees of right ventricular dilatation and to determine the predictors of peak oxygen pulse after pulmonary valve replacement. The mean and median age at pulmonary valve replacement was 27 years. Mean pre-procedural right ventricular end-diastolic volume was 182 ml/m2. Out of 24 patients, 15 had abnormal peak oxygen pulse before pulmonary valve replacement. We did not observe a significant increase in peak oxygen pulse after pulmonary valve replacement (p=0.76). Among cardiopulmonary test/MRI/historical pre-procedural parameters, peak oxygen pulse appeared to be the best predictor of peak oxygen pulse after pulmonary valve replacement (positive and negative predictive values, respectively, 0.94 and 1). After pulmonary valve replacement, peak oxygen pulse was well correlated with left ventricular stroke and end-diastolic volumes (r=0.67 and 0.68, respectively). Our study confirms the absence of an effect of pulmonary valve replacement on peak oxygen pulse whatever the initial right ventricular volume, reflecting possible irreversible right and/or left ventricle lesions. Pre-procedural peak oxygen pulse seemed to well predict post-procedural peak oxygen pulse. These results encourage discussions on pulmonary valve replacement in patients showing any decrease in peak oxygen pulse during their follow-up.
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Joynt MR, Yu S, Dorfman AL, Ghadimi Mahani M, Agarwal PP, Lu JC. Differential Impact of Pulmonary Regurgitation on Patients With Surgically Repaired Pulmonary Stenosis Versus Tetralogy of Fallot. Am J Cardiol 2016; 117:289-94. [PMID: 26651611 DOI: 10.1016/j.amjcard.2015.10.025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 10/22/2015] [Accepted: 10/22/2015] [Indexed: 11/18/2022]
Abstract
Patients with repaired pulmonary stenosis (PS) or tetralogy of Fallot (TOF) both develop pulmonary regurgitation (PR) leading to right ventricular (RV) dilatation and dysfunction. We aimed to characterize differential effects of chronic PR in these populations. Patients with surgically repaired PS were matched 1:2 by age and PR fraction with patients with TOF. Patients with previous pulmonary valve replacement were excluded. Cardiovascular magnetic resonance data were compared; peak longitudinal and circumferential systolic strain by feature tracking were compared to evaluate differential contribution of the RV sinus and outflow tract, respectively. PS (n = 24, 41 ± 13 years old) and TOF (n = 47, 39 ± 13 years old) patients did not differ in RV end-diastolic volume (153 ± 45 vs 154 ± 45 ml/m(2), p = 0.99) or diastolic function. However, patients with PS had preserved RV ejection fraction (54.3 ± 4.4% vs 48.0 ± 7.1%, p <0.0001). Differences were greater in RV circumferential (-15.8 ± 3.3 vs -11.8 ± 3.4, p <0.0001) than longitudinal strain (-18.0 ± 3.8 vs -15.9 ± 3.8, p = 0.04), with particular decrease in the infundibulum (-17.4 ± 7.5 vs -6.8 ± 6.3, p <0.0001). Late gadolinium enhancement in the RV outflow tract was more frequent in patients with TOF (70.2% vs 45.8%, p = 0.001). In conclusion, surgical repair of PS leads to similar RV dilatation and diastolic dysfunction compared to patients with TOF, but differential effects on ventricular systolic function, largely related to differences in the outflow tract. With different patterns of scarring and ventricular remodeling, further study is needed to clarify whether criteria for pulmonary valve replacement in patients with PS should differ from those with TOF.
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Affiliation(s)
- Michael R Joynt
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan.
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan; Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Maryam Ghadimi Mahani
- Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan; Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan; Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
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O'Meagher S, Seneviratne M, Skilton MR, Munoz PA, Robinson PJ, Malitz N, Tanous DJ, Celermajer DS, Puranik R. Right Ventricular Mass is Associated with Exercise Capacity in Adults with Repaired Tetralogy of Fallot. Pediatr Cardiol 2015; 36:1225-31. [PMID: 25795311 DOI: 10.1007/s00246-015-1150-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 03/13/2015] [Indexed: 11/25/2022]
Abstract
The relationship between exercise capacity and right ventricular (RV) structure and function in adult repaired tetralogy of Fallot (TOF) is poorly understood. We therefore aimed to examine the relationships between cardiac MRI and cardiopulmonary exercise test variables in adult repaired TOF patients. In particular, we sought to determine the role of RV mass in determining exercise capacity. Eighty-two adult repaired TOF patients (age at evaluation 26 ± 10 years; mean age at repair 2.5 ± 2.8 years; 23.3 ± 7.9 years since repair; 53 males) (including nine patients with tetralogy-type pulmonary atresia with ventricular septal defect) were prospectively recruited to undergo cardiac MRI and cardiopulmonary exercise testing. As expected, these repaired TOF patients had RV dilatation (indexed RV end-diastolic volume: 153 ± 43.9 mL/m(2)), moderate-severe pulmonary regurgitation (pulmonary regurgitant fraction: 33 ± 14 %) and preserved left (LV ejection fraction: 59 ± 8 %) and RV systolic function (RV ejection fraction: 51 ± 7 %). Exercise capacity was near-normal (peak work: 88 ± 17 % predicted; peak oxygen consumption: 84 ± 17 % predicted). Peak work exhibited a significant positive correlation with RV mass in univariate analysis (r = 0.45, p < 0.001) and (independent of other cardiac MRI variables) in multivariate analyses. For each 10 g higher RV mass, peak work was 8 W higher. Peak work exhibits a significant positive correlation with RV mass, independent of other cardiac MRI variables. RV mass measured on cardiac MRI may provide a novel marker of clinical progress in adult patients with repaired TOF.
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Affiliation(s)
- Shamus O'Meagher
- Faculty of Medicine, The University of Sydney, Sydney, Australia,
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Shafer KM, Mann N, Hehn R, Ubeda Tikkanen A, Valente AM, Geva T, Gauthier N, Rhodes J. Relationship between Exercise Parameters and Noninvasive Indices of Right Ventricular Function in Patients with Biventricular Circulation and Systemic Right Ventricle. CONGENIT HEART DIS 2015; 10:457-65. [PMID: 25597937 DOI: 10.1111/chd.12248] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2014] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In patients with systemic right ventricles (RVs) in a biventricular circulation, exercise capacity and RV function often deteriorate over time and echocardiographic assessment of systemic RV function is difficult. The purpose of this study was to examine the relationship between exercise capacity and RV function and to determine which noninvasive imaging parameters correlate most closely with exercise capacity. DESIGN Patients with a systemic RV (D-loop transposition of the great arteries [TGA] after atrial switch procedure or physiologically "corrected" TGA) who underwent cardiopulmonary exercise testing (CPX) and noninvasive imaging (cardiac magnetic resonance [CMR] and echocardiography [echo]) within 1 year of CPX were identified. Regression analysis was used to evaluate the relationship between exercise variables and noninvasive indices of ventricular function. RESULTS We identified 92 patients with 149 encounters (mean age 31.0 years, 61% men, 70% D-loop TGA) meeting inclusion criteria. Statistically significant correlations between % predicted peak oxygen uptake (%pVO2 ) and RV ejection fraction (EF) (r = 0.29, P = .0007), indexed RV end-systolic volume (r = -0.25, P = .002), and Tei index (r = -0.22, P = .03) were found. In patients without additional hemodynamically significant lesions, the correlations between %pVO2 and RV EF (r = 0.37, P = .0007) and the Tei index (r = -0.28, P = .03) strengthened and a correlation emerged between %pVO2 and dP/dtic (r = 0.31, P = .007). On multivariable analysis, Tei index was the only statistically significant correlate of %pVO2 (P = .04). CONCLUSIONS In patients with systemic RVs in a biventricular circulation, CMR-derived RVEF and echo-derived Tei index correlate with %pVO2 . On multivariable analysis, the Tei index was the strongest predictor of peak %pVO2 response.
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Affiliation(s)
- Keri M Shafer
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Nina Mann
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Rebecca Hehn
- Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Ana Ubeda Tikkanen
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Tal Geva
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
| | - Naomi Gauthier
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jonathan Rhodes
- Department of Cardiology, Boston Children's Hospital, Boston, Mass, USA.,Department of Pediatrics, Harvard Medical School, Boston, Mass, USA
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O'Meagher S, Munoz PA, Muthurangu V, Robinson PJ, Malitz N, Tanous DJ, Celermajer DS, Puranik R. Mechanisms of maintained exercise capacity in adults with repaired tetralogy of Fallot. Int J Cardiol 2014; 177:178-81. [PMID: 25499372 DOI: 10.1016/j.ijcard.2014.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Revised: 08/21/2014] [Accepted: 09/15/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND The mechanisms whereby cardiac output is augmented with exercise in adult repaired tetralogy of Fallot (TOF) are poorly characterised. METHODS 16 repaired TOF patients (25 ± 7 years of age) and 8 age and sex matched controls (25 ± 4 years of age) underwent cardiopulmonary exercise testing and then real-time cardiac MRI (1.5 T) at rest and whilst exercising within the scanner, aiming for 30% heart rate reserve (Level 1) and 60% heart rate reserve (Level 2), using a custom-built MRI compatible foot pedal device. RESULTS At rest, TOF patients had severely dilated RVs (indexed RV end-diastolic volume: 149 ± 37 mL/m(2)), moderate-severe PR (regurgitant fraction 35 ± 12%), normal RV fractional area change (FAC) (52 ± 7%) and very mildly impaired exercise capacity (83 ± 15% of predicted maximal work rate). Heart rate and RV FAC increased significantly in TOF patients (75 ± 10 vs 123 ± 17 beats per minute, p<0.001; 44 ± 7 vs 51 ± 10%, p=0.025), and similarly in control subjects (70 ± 11 vs 127 ± 12 beats per minute, p<0.001; 49 ± 7 vs 61 ± 9%, p=0.003), when rest was compared to Level 2. PR fraction decreased significantly but only modestly, from rest to Level 2 in TOF patients (37 ± 15 to 31 ± 15%, p=0.002). Pulmonary artery net forward flow was maintained and did not significantly increase from rest to Level 2 in TOF patients (70 ± 19 vs 69 ± 12 mL/beat, p=0.854) or controls (93 ± 9 vs 95 ± 21 mL/beat, p=0.648). CONCLUSIONS During exercise in repaired TOF subjects with dilated RV and free PR, increased total RV output per minute was facilitated by an increase in heart rate, an increase in RV FAC and a decrease in PR fraction.
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Affiliation(s)
- Shamus O'Meagher
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
| | - Phillip A Munoz
- Royal Prince Alfred Hospital, Department of Respiratory and Sleep Medicine, Sydney, Australia.
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, Centre for Cardiovascular Imaging, London, United Kingdom; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, London, United Kingdom.
| | - Peter J Robinson
- Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia; Westmead Hospital, Department of Cardiology, Sydney, Australia.
| | | | - David J Tanous
- Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia; Westmead Hospital, Department of Cardiology, Sydney, Australia.
| | - David S Celermajer
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
| | - Rajesh Puranik
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
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O’Meagher S, Ganigara M, Tanous DJ, Celermajer DS, Puranik R. Progress of right ventricular dilatation in adults with repaired tetralogy of Fallot and free pulmonary regurgitation. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VESSELS 2014; 3:28-31. [PMID: 29450166 PMCID: PMC5801270 DOI: 10.1016/j.ijchv.2014.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/21/2014] [Indexed: 11/13/2022]
Abstract
Background The time course of progressive dilatation of the right ventricle (RV) in adults with pulmonary regurgitation (PR) late after repair of tetralogy of Fallot (TOF) is poorly characterized. Methods We analysed cardiac MRI data (1.5 T) from 14 adult repaired TOF patients (26 ± 11 years of age) with dilated RVs and known significant PR, on 2 separate visits with a between MRI period of 2.1 ± 1.0 years. Results Indexed RV end diastolic volume (RVEDVi) increased over 2 years (142 ± 19 to 151 ± 20 mL/m2, p = 0.005; change = 8.4 ± 9.3 mL/m2, range = − 6 to 26 mL/m2; annual mL/m2 increase = 4.3 ± 4.6; annual percentage increase = 3.1 ± 3.3%), whilst RV ejection fraction decreased (53 ± 8 to 49 ± 7 %, p = 0.039). RV muscular corpus (RVMC) EDVi significantly increased (130 ± 19 to 138 ± 20 mL/m2, p = 0.014), whereas RV outflow tract (RVOT) EDVi did not (12 ± 7 vs 13 ± 6 mL/m2, p = 0.390). No other RV or LV measures significantly changed during the inter-MRI period. The change in RVEDVi correlated significantly with LV end diastolic volume (r = − 0.582, p = 0.029), RVEDVi:LVEDVi (r = 0.6, p = 0.023) and RVMC EDVi (r = 0.9, p < 0.001) but not RVOT EDVi (r = 0.225, p = 0.459). Conclusions Adult repaired TOF patients with free PR experienced a mean 3.1%, or 4.3 mL/m2, annual increase in RVEDVi, unrelated to the initial RVEDVi or PR fraction. The increase in RVEDVi was due to RVMC rather than RVOT dilatation. This provides a guide to the frequency of MR surveillance and insights into the natural history of progressive RV dilatation in this setting.
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22
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Buber J, Rhodes J. Exercise Physiology and Testing in Adult Patients with Congenital Heart Disease. Heart Fail Clin 2014; 10:23-33. [DOI: 10.1016/j.hfc.2013.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bove T, Vandekerckhove K, Devos D, Panzer J, De Groote K, De Wilde H, De Wolf D, De Backer J, Demulier L, François K. Functional analysis of the anatomical right ventricular components: should assessment of right ventricular function after repair of tetralogy of Fallot be refined? Eur J Cardiothorac Surg 2013; 45:e6-12. [PMID: 24186927 DOI: 10.1093/ejcts/ezt505] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Follow-up after tetralogy of Fallot (ToF) repair is directed to detect timely right ventricular (RV) dysfunction by following pulmonary regurgitation and global RV size, with little attention for the effective contribution of regional RV dysfunction. This study investigates the contribution of regional RV dysfunction on exercise capacity after ToF repair. METHODS Forty-two patients were investigated with cardiac magnetic resonance imaging for regional RV dysfunction in relation to global RV function by functional quantification of the sinus and outflow part of the RV. The impact of regional and global RV dysfunction on clinical status was studied by exercise testing. RESULTS Global RV function was lower than sinus function (ejection fraction (EF) 52±12% vs 58±10%, P<0.001), attributable to the adverse influence of right ventricular outflow tract (RVOT) dysfunction (EF 34±17%). Percent predicted peak VO2 correlated better with the RV sinus ejection fraction compared with the global RV ejection fraction (r=0.51, P=0.001 vs r=0.44, P=0.004). Multivariate analysis revealed the EF of RV sinus (β=0.34, 95% CI 0.07-0.61, P=0.013) and the extent of RVOT akinesia (β=-0.28, 95% CI -0.50; -0.06, P=0.015) as significant determinants of exercise capacity. Impaired exercise performance occurred in 43% of the patients, and was independently determined by the type of repair (transventricular vs transatrial: OR 6.0, 95% CI 1.31-17.3, P=0.02) by associating greater sinus and RVOT dysfunction. CONCLUSION Functional analysis of the RV components shows that exercise capacity after repair of ToF is better predicted by systolic function of the RV sinus as the extent of RVOT dysfunction commonly leads to underestimation of global RV function. This method of differential quantification of regional RV function might be more appropriate than assessment of global RV function during the long-term follow-up of repaired ToF patients.
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Affiliation(s)
- Thierry Bove
- Department of Cardiac Surgery, University Hospital of Ghent, Ghent, Belgium
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Ordovas KG, Muzzarelli S, Hope MD, Naeger DM, Karl T, Reddy GP, Marchiori E, Higgins CB. Cardiovascular MR Imaging after Surgical Correction of Tetralogy of Fallot: Approach Based on Understanding of Surgical Procedures. Radiographics 2013; 33:1037-52. [DOI: 10.1148/rg.334115084] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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O'Byrne ML, Mercer-Rosa L, Ingall E, McBride MG, Paridon S, Goldmuntz E. Habitual exercise correlates with exercise performance in patients with conotruncal abnormalities. Pediatr Cardiol 2013; 34:853-60. [PMID: 23104594 DOI: 10.1007/s00246-012-0556-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 10/04/2012] [Indexed: 12/25/2022]
Abstract
Cardiopulmonary exercise testing (CPET), particularly maximal oxygen consumption (VO2max), has been used to assess the outcome for patients with palliated congenital heart disease (CHD). Small studies correlating VO2max with noninvasive imaging measures of ventricular function have led to the hypothesis that VO2max reflects cardiac performance. In other settings, physical training is associated with increased VO2max. The authors hypothesized that habitual exercise correlates with VO2max to a greater degree than ventricular function in a relatively healthy cohort of patients with palliated CHD. The habitual exercise behavior of 208 subjects with conotruncal abnormalities (tetralogy of Fallot, truncus arteriosus, and interrupted aortic arch) at the time of previously performed, study-based CPET and cardiac magnetic resonance imaging (CMR) were retrospectively assessed via questionnaire. The association of VO2max with habitual exercise duration and CMR measures of ventricular function was tested. Of 208 subjects, 89 (43 %) completed questionnaires, and 78 % of the 89 patients had a concurrent CMR. The mean VO2max was 76 ± 21 % of that predicted. The CMR-assessed left ventricular ejection fraction was 67.6 ± 7.4 %. The hours of habitual exercise per week correlated with VO2max (p < 0.001; r (2) = 0.14). No association was found between right and left ventricular ejection fraction, cardiac index, or right ventricular end-diastolic volume and VO2max. In this study, VO2max correlated with habitual exercise to a greater degree than CMR measurements of ventricular function. These findings highlight the importance of considering the contribution of noncardiac factors when exercise data in both clinical and research settings are interpreted. The contribution of these factors to clinical outcomes deserves further study.
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Affiliation(s)
- Michael L O'Byrne
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19147, USA.
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Bolognesi D. A teenager with tetralogy of fallot becomes a soccer player. Am J Case Rep 2013; 14:380-4. [PMID: 24116262 PMCID: PMC3789579 DOI: 10.12659/ajcr.889440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 07/10/2013] [Indexed: 11/17/2022] Open
Abstract
Patient: Male, 0 Final Diagnosis: Tetralogy of Fallot Symptoms: — Medication: — Clinical Procedure: — Specialty: Cardiology
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Menon SC, Kaza AK, Puchalski MD. Effect of ventricular size and function on exercise performance and the electrocardiogram in repaired tetralogy of Fallot with pure pulmonary regurgitation. Ann Pediatr Cardiol 2012; 5:151-5. [PMID: 23129904 PMCID: PMC3487203 DOI: 10.4103/0974-2069.99617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: In repaired tetralogy of Fallot (TOF), exercise test parameters like peak oxygen uptake and ventilatory efficiency predict mortality. Studies have also suggested cardiac magnetic resonance (CMR)-derived right ventricular (RV) size threshold values for pulmonary valve replacement in repaired TOF. However, effects of proposed RV size on exercise capacity and morbidity are not known. Methods: The relationship between CMR-derived ventricular size, function, and pulmonary regurgitation (PR) and NYHA class, exercise performance, and electrocardiogram (ECG) was studied in patients of repaired TOF with pure PR in a retrospective review of records. Results: 46 patients (22 females), mean age 14 years (8–30.8), were studied. There was no relationship between CMR-derived ventricular size, function, or PR and exercise test parameters, or NYHA class. RV end systolic and end diastolic volume correlated positively with the degree of PR. QRS duration on ECG correlated positively with RV end-diastolic volume (P < 0.01, r2 = 0.34) and PR (P < 0.01, r2 = 0.52). Conclusions: In repaired TOF and pure PR, there is no correlation between ventricular size or function and exercise performance. RV size increases with increasing PR. Timing of pulmonary valve replacement in TOF with pure PR needs further prospective evaluation for its effect on morbidity and mortality.
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Affiliation(s)
- Shaji C Menon
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
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Śpiewak M, Małek ŁA, Petryka J, Mazurkiewicz Ł, Werys K, Biernacka EK, Kowalski M, Hoffman P, Demkow M, Miśko J, Rużyłło W. Repaired Tetralogy of Fallot: Ratio of Right Ventricular Volume to Left Ventricular Volume as a Marker of Right Ventricular Dilatation. Radiology 2012; 265:78-86. [DOI: 10.1148/radiol.12120051] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Alghamdi MH, Mertens L, Lee W, Yoo SJ, Grosse-Wortmann L. Longitudinal right ventricular function is a better predictor of right ventricular contribution to exercise performance than global or outflow tract ejection fraction in tetralogy of Fallot: a combined echocardiography and magnetic resonance study. Eur Heart J Cardiovasc Imaging 2012; 14:235-9. [PMID: 22782958 DOI: 10.1093/ehjci/jes137] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS The contribution of the systolic function of the right ventricular (RV) outflow tract (RVOT) and of longitudinal shortening of the body of the right ventricle to global RV systolic function and exercise capacity in patients after tetralogy of Fallot (TOF) repair is unclear. Our aim was to characterize the functional role of the RVOT and to identify the most suitable method of assessing RV systolic function in clinical practice. METHODS The cardiac magnetic resonance (CMR) studies, echocardiograms, and medical records of 50 consecutive patients with repaired TOF who underwent CMR were reviewed. The volumes of the RVOT and of the remainder of the RV were measured separately. Echocardiographic RV strain measurements based on ultrasound speckle tracking were collected. RESULTS After excluding the akinetic RVOT, RVEF was statistically higher (47.1 vs. 45.0%, P< 0.0001) but the average increase in EF was small. The correlations of fractional area change and global longitudinal strain, both by echocardiography, with global RVEF were moderate (r= 0.59, P= 0.0001 and r= 0.56, P= 0.0004, respectively). The correlation between RVEF and predicted maximal oxygen consumption (VO(2)max-predicted) was weak, regardless of whether the akinetic RVOT was included or not (r= 0.33, P= 0.049 and r= 0.36, P= 0.03, respectively). Of all imaging parameters, echocardiographic RV longitudinal strain correlated best with VO(2)max-predicted (r= 0.66, P= 0.0001). CONCLUSIONS In patients following TOF repair, echocardiographic and CMR descriptors of global RV systolic function are, at best, weak predictors of exercise tolerance. Longitudinal function of the RV, measured remotely from the RVOT, may be a more important determinant of exercise performance than global RVEF in patients with aneurismal RVOTs.
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Affiliation(s)
- Mohammed H Alghamdi
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, 555 University Ave, Toronto, Ontario, Canada
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Lu JC, Cotts TB, Dorfman AL. Diastolic function and patient-reported quality of life for adolescents and adults with repaired tetralogy of Fallot: a tissue Doppler study. Pediatr Cardiol 2012; 33:618-24. [PMID: 22327228 DOI: 10.1007/s00246-012-0189-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 11/19/2011] [Indexed: 11/26/2022]
Abstract
Left ventricular systolic function is an important indicator of clinical well-being and outcomes for patients with repaired tetralogy of Fallot (TOF). This study tested the hypothesis that left ventricular diastolic function by pulsed-wave tissue Doppler is associated with quality of life in this population. In this study, 38 subjects (age, 31.0 ± 14.1 years) with repaired TOF underwent echocardiogram and completed the Short-Form 36, version 2, a validated quality-of-life assessment, within a median of 0 days (range, 0-90 days). Available cardiovascular magnetic resonance data within 1 year after the echocardiogram were analyzed. The ratio of peak early inflow to peak early annular velocity (E/E') at the lateral mitral annulus correlated inversely with the ability to participate in usual activities without physical limitations (r = -0.37; p = 0.02), whereas the right ventricular diastolic indices were not predictive. The relation of left ventricular diastolic function to quality of life was independent of left ventricular systolic function. This may be related to adverse ventricular-ventricular interactions because lateral mitral E/E' correlated with tricuspid E/E' (r = 0.46; p = 0.008) and the right ventricular myocardial performance index (r = 0.42; p = 0.01). Pulsed-wave tissue Doppler of the mitral annulus is a useful tool in this population and may potentially identify patients in need of intervention before the development of left or right ventricular systolic dysfunction.
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Affiliation(s)
- Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Congenital Heart Center, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109-4204, USA.
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Batra AS, McElhinney DB, Wang W, Zakheim R, Garofano RP, Daniels C, Yung D, Cooper DM, Rhodes J. Cardiopulmonary exercise function among patients undergoing transcatheter pulmonary valve implantation in the US Melody valve investigational trial. Am Heart J 2012; 163:280-7. [PMID: 22305848 DOI: 10.1016/j.ahj.2011.10.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 10/26/2011] [Indexed: 10/14/2022]
Abstract
OBJECTIVES We assessed the hypothesis that there is an improvement in clinical and physiologic parameters of cardiopulmonary exercise testing (CPET) after implantation of a transcatheter pulmonary valve (TPV). BACKGROUND Transcatheter pulmonary valve provides a new tool for treating conduit stenosis and regurgitation in patients with right ventricle (RV) to pulmonary artery conduit dysfunction. METHODS Patients who underwent a TPV placement between January 2007 and January 2010 (N = 150) were investigated with a standardized CPET protocol before and at 6 months after TPV placement. Cardiopulmonary exercise testing was performed on a mechanically braked cycle ergometer with respiratory gas exchange analysis. RESULTS Six months post TPV, small but statistically significant improvements were observed in the maximum workload (65.0% ± 18.8% to 68.3% ± 20.3% predicted, P < .001) and the ratio of minute ventilation to CO(2) production at the anaerobic threshold (30.8 ± 4.7 to 29.1 ± 4.1, P < .001). There was no significant change in peak oxygen consumption (VO(2)). Patients with pre-TPV hemodynamics consistent with RV dysfunction and patients with a lower pre-TPV peak VO(2) tended to have the greatest improvement in peak VO(2). The correlation between TPV-related improvements in peak VO(2) and baseline clinical variables were weak, however, and these variables could not be used to reliably identify patients likely to have improved peak VO(2) after TPV. CONCLUSION In patients with RV to pulmonary artery conduit dysfunction, TPV is associated with modest improvement in exercise capacity and gas exchange efficiency during exercise.
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Takken T, Giardini A, Reybrouck T, Gewillig M, Hövels-Gürich HH, Longmuir PE, McCrindle BW, Paridon SM, Hager A. Recommendations for physical activity, recreation sport, and exercise training in paediatric patients with congenital heart disease: a report from the Exercise, Basic & Translational Research Section of the European Association of Cardiovascular Prevention and Rehabilitation, the European Congenital Heart and Lung Exercise Group, and the Association for European Paediatric Cardiology. Eur J Prev Cardiol 2011; 19:1034-65. [DOI: 10.1177/1741826711420000] [Citation(s) in RCA: 161] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- T Takken
- Child Development & Exercise Center, Wilhelmina Children's Hospital, University Medical Center Utrecht, The Netherlands
| | - A Giardini
- Cardiorespiratory Unit, Great Ormond Street Hospital For Children – UCL Institute of Child Health, London, UK
| | - T Reybrouck
- Department of Cardiovascular Rehabilitation University Hospitals Leuven (campus Gasthuisberg); Department Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - M Gewillig
- Department of Pediatric Cardiology, University Hospitals Leuven (campus Gasthuisberg), Leuven, Belgium
| | - HH Hövels-Gürich
- Department of Paediatric Cardiology, Children's Heart Centre, University Hospital, Aachen University of Technology, Aachen, Germany
| | - PE Longmuir
- Hospital for Sick Children (Labatt Family Heart Centre), Toronto, Ontario, Canda; University of Toronto (Department of Physical Therapy) Toronto, Ontario Canada, Children's Hospital of Eastern Ontario (Healthy Active Living and Obesity Research Unit), Ottawa, Ontario, Canada
| | - BW McCrindle
- Labatt Family Heart Centre, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - SM Paridon
- Cardiology Division, The Children's Hospital of Philadelphia Professor of Pediatrics The Perlman School of Medicine The University of Pennsylvania
| | - A Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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Kipps AK, Graham DA, Harrild DM, Lewis E, Powell AJ, Rhodes J. Longitudinal exercise capacity of patients with repaired tetralogy of fallot. Am J Cardiol 2011; 108:99-105. [PMID: 21529748 DOI: 10.1016/j.amjcard.2011.02.349] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 02/22/2011] [Accepted: 02/22/2011] [Indexed: 11/25/2022]
Abstract
Patients with repaired tetralogy of Fallot have a reduced percentage of predicted peak oxygen consumption (VO(2)) and percentage of oxygen pulse (O(2)P%) compared to healthy controls. Because data regarding the progression of exercise intolerance in these patients is limited, we sought to analyze the serial exercise data from patients with Tetralogy of Fallot to quantify the changes in their exercise capacity over time and to identify associations with clinical and cardiac magnetic resonance imaging variables. The data from cardiopulmonary exercise tests (CPXs) from 2002 to 2010 for patients with repaired tetralogy of Fallot with ≥2 CPXs separated by ≥12 months were analyzed. Tests occurring after interventional catheterization or surgery were excluded. A total of 70 patients had 179 CPXs. They had a median age at the initial study of 23.6 years and an interval between the first and last CPX of 2.8 years. At the initial CPX, the peak VO(2) was 27.6 ± 8.8 ml/kg/min (78 ± 19% of predicted), and the peak O(2)P% was 89 ± 22% of predicted. At the most recent study, the peak VO(2) averaged 25.0 ± 7.4 ml/kg/min (73 ± 16% of predicted), and the peak O(2)P% averaged 83 ± 20% (p <0.01) for each versus the initial CPX. The decrease in the peak VO(2) was strongly associated with a decrease in O(2)P% and an increase (worsening) in the slope of the minute ventilation-versus-carbon dioxide production relation. Changes in the peak VO(2) did not correlate with concomitant changes in any other CPX variable. The rate of decrease was not related to a history of shunt palliation, age at CPX, or any other baseline clinical parameter, including cardiac magnetic resonance measurements. In conclusion, the exercise capacity of patients with repaired tetralogy of Fallot tends to decrease over time. This deterioration is variable and unpredictable and is primarily related to a decrease in the forward stroke volume at peak exercise.
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Śpiewak M, Biernacka EK, Małek ŁA, Petryka J, Kowalski M, Miłosz B, Żabicka M, Miśko J, Rużyłło W. Right ventricular outflow tract obstruction as a confounding factor in the assessment of the impact of pulmonary regurgitation on the right ventricular size and function in patients after repair of tetralogy of fallot. J Magn Reson Imaging 2011; 33:1040-6. [DOI: 10.1002/jmri.22532] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Lu JC, Cotts TB, Agarwal PP, Attili AK, Dorfman AL. Relation of right ventricular dilation, age of repair, and restrictive right ventricular physiology with patient-reported quality of life in adolescents and adults with repaired tetralogy of fallot. Am J Cardiol 2010; 106:1798-802. [PMID: 21126623 DOI: 10.1016/j.amjcard.2010.08.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 08/11/2010] [Accepted: 08/11/2010] [Indexed: 11/17/2022]
Abstract
The present study aimed to determine the predictors of patient-reported quality of life and restrictive right ventricular (RV) physiology in adolescents and adults with repaired tetralogy of Fallot. A total of 62 patients (median age 28.5 years, range 14 to 69) undergoing cardiovascular magnetic resonance imaging completed the Short Form 36-item questionnaire, version 2, a validated quality of life assessment. RV inflow curves were generated from the sum of tricuspid inflow and pulmonary insufficiency. The patient-reported quality of life was comparable to population norms. Patients repaired after 1 year of age showed a strong trend toward a greater likelihood of physical component summary age-adjusted z-score ≤-1 (odds ratio 7.50, 95% confidence interval 0.90 to 62.3, p = 0.06). Patients with a RV ejection fraction of <45% reported decreased physical component summary (p = 0.02) and physical functioning (p = 0.02) scores. The RV end-diastolic volume, pulmonary regurgitation, and diastolic indexes did not predict the quality of life. The indexed RV end-diastolic volume was related to diastolic abnormalities, correlating with a greater peak early filling rate (r = 0.71, p <0.0001), ratio of peak early to atrial filling rates (r = 0.45, p = 0.006), and showing a strong trend with the end-diastolic forward flow in the pulmonary trunk (odds ratio 2.67 for moderate dilation and 3.50 for severe dilation, p = 0.06). Patients who underwent repair before 1 year old were more likely to have end-diastolic forward flow (15 of 17 vs 25 of 42, p = 0.03). In conclusion, the RV ejection fraction and age of repair were the best predictors of quality of life in this population, in whom end-diastolic forward flow and associated diastolic parameters appeared to reflect an overdistended ventricle, which might suggest a role for early pulmonary valve replacement.
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Affiliation(s)
- Jimmy C Lu
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, USA.
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Rhodes J, Ubeda Tikkanen A, Jenkins KJ. Exercise Testing and Training in Children With Congenital Heart Disease. Circulation 2010; 122:1957-67. [DOI: 10.1161/circulationaha.110.958025] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan Rhodes
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
| | - Ana Ubeda Tikkanen
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
| | - Kathy J. Jenkins
- From the Department of Cardiology, Children's Hospital, Boston, Mass (J.R., K.J.J.) and the Departments of Rehabilitation and Pediatric Cardiology, Hospital Gregorio Marañón, Madrid, Spain (A.U.T.)
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Geva T, Gauvreau K, Powell AJ, Cecchin F, Rhodes J, Geva J, del Nido P. Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery. Circulation 2010; 122:S201-8. [PMID: 20837914 DOI: 10.1161/circulationaha.110.951178] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Although pulmonary valve replacement (PVR) is effective in reducing right ventricular (RV) volume overload in patients with chronic pulmonary regurgitation, persistent RV dysfunction and subsequent adverse clinical outcomes have been reported. This trial was conducted to investigate whether the addition of surgical RV remodeling with exclusion of scar tissue to PVR would result in improved RV function and laboratory and clinical parameters, as compared with PVR alone. METHODS AND RESULTS Between February 2004 and October 2008, 64 patients who underwent RV outflow tract procedures in early childhood had more than or equal to moderate pulmonary regurgitation, and fulfilled defined criteria for PVR were randomly assigned to undergo either PVR alone (n=34) or PVR with surgical RV remodeling (n=30). No significant difference was observed in the primary outcome (change in RV ejection fraction, -2±7% in the PVR alone group and -1±7% in the PVR with RV remodeling group; P=0.38) or in any of the secondary outcomes at 6-month postoperative follow-up. Multivariable analysis of the entire cohort identified preoperative RV end-systolic volume index <90 mL/m(2) and QRS duration <140 ms to be associated with optimal postoperative outcome (normal RV size and function), and RV ejection fraction <45% and QRS duration ≥160 ms to be associated with suboptimal postoperative outcome (RV dilatation and dysfunction). CONCLUSIONS The addition of surgical remodeling of the RV to PVR in patients with chronic pulmonary regurgitation did not result in a measurable early benefit. Referral to PVR based on QRS duration, RV end-systolic volume, or RV ejection fraction may be beneficial. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00112320.
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Affiliation(s)
- Tal Geva
- Department of Cardiology, Children's Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA.
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Nath DS, Nussbaum DP, Yurko C, Ragab OM, Shin AJ, Kumar SR, Starnes VA, Wells WJ. Pulmonary homograft monocusp reconstruction of the right ventricular outflow tract: outcomes to the intermediate term. Ann Thorac Surg 2010; 90:42-9. [PMID: 20609745 DOI: 10.1016/j.athoracsur.2010.03.045] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 03/14/2010] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND There is limited information on longer-term outcomes of pulmonary homograft monocusp (PHM) reconstruction of the right ventricular outflow tract (RVOT). METHODS A retrospective review of 131 consecutive patients undergoing RVOT reconstruction with PHM was completed. RESULTS Median age was 7.6 months (range, 1 day to 14 years) and weight was 7.3 kg (range, 2 to 65 kg). Most patients (108 of 131; 82%) underwent repair for Tetralogy. After PHM, median duration of mechanical ventilation was 1 day (range, 0 to 89) and hospital stay was 6.5 days (range, 2 to 137). Hospital mortality was 2% (3 of 131) with 1 patient undergoing early replacement of PHM. Echocardiogram at hospital discharge demonstrated peak RVOT gradient of 16 mm Hg (range, 4 to 64 mm Hg); and pulmonary insufficiency was absent/trivial in 40%, mild in 42%, moderate in 16%, and severe in 2%. Follow-up is completed in 91% of hospital survivors at a median of 5 years (range, 1 to 12). There were 5 late deaths, with an actuarial survival of 96% +/- 3.7%, 94% +/- 4.6%, and 89% +/- 9.2% at 1 year, 5 years, and 10 years, respectively. There were 24 reinterventions, including 10 pulmonary valve replacements. Median time to valve replacement was 1.9 years (range, 0.4 to 4.6). Actuarial freedom from pulmonary valve replacement was 97% +/- 3.0%, 90% +/- 6.1%, and 85% +/- 10.3% at 1 year, 5 years, and 10 years, respectively. Echocardiogram at last follow-up demonstrated no increase in RVOT gradient compared with hospital discharge (16 mm Hg), but there was significant increase in pulmonary insufficiency (mild 27%, moderate 39%, severe 34%). CONCLUSIONS Pulmonary homograft monocusp reconstruction is an alternative strategy for RVOT reconstruction and provides early but gradually diminishing protection against pulmonary insufficiency without a risk of stenosis. As expected, PHM function decreases over time as the RVOT grows and the homograft tissue undergoes structural deterioration.
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Affiliation(s)
- Dilip S Nath
- Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Division of Cardiothoracic Surgery, Los Angeles, California, USA
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Long-term pulmonary regurgitation following balloon valvuloplasty for pulmonary stenosis risk factors and relationship to exercise capacity and ventricular volume and function. J Am Coll Cardiol 2010; 55:1041-7. [PMID: 20202522 DOI: 10.1016/j.jacc.2010.01.016] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Revised: 12/23/2009] [Accepted: 01/02/2010] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to examine the prevalence and predictors of pulmonary regurgitation (PR) following balloon dilation (BD) for pulmonary stenosis (PS) and to investigate its impact on ventricular volume and function, and exercise tolerance. BACKGROUND Balloon pulmonary valvuloplasty relieves PS but can cause late PR. The sequelae of isolated PR are not well understood. METHODS Patients were at least 7 years of age and 5 years removed from BD, and had no other form of congenital heart disease or significant residual PS. Cardiac magnetic resonance imaging and exercise testing were performed prospectively to quantify PR fraction, ventricular volumes and function, and exercise capacity. RESULTS Forty-one patients underwent testing a median of 13.1 years after BD. The median PR fraction was 10%; 14 patients (34%) had PR fraction >15%; 7 (17%) had PR >30%. PR fraction was associated with age at dilation (ln-transformed, R = -0.47, p = 0.002) and balloon:annulus ratio (R = 0.57, p < 0.001). The mean right ventricular (RV) end-diastolic volume z-score was 1.8 +/- 1.9; RV dilation (z-score > or =2) was present in 14/35 patients (40%). PR fraction correlated closely with indexed RV end-diastolic volume (R = 0.79, p < 0.001) and modestly with RV ejection fraction (R = 0.50, p < 0.001). Overall, peak oxygen consumption (Vo(2)) (% predicted) was below average (92 +/- 17%, p = 0.006). Patients with PR fraction >15% had significantly lower peak Vo(2) than those with less PR (85 +/- 17% vs. 96 +/- 16%, p = 0.03). CONCLUSIONS Mild PR and RV dilation are common in the long term following BD. A PR fraction >15% is associated with lower peak Vo(2), suggesting that isolated PR and consequent RV dilation are related to impaired exercise cardiopulmonary function.
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Lurz P, Giardini A, Taylor AM, Nordmeyer J, Muthurangu V, Odendaal D, Mist B, Khambadkone S, Schievano S, Bonhoeffer P, Derrick G. Effect of altering pathologic right ventricular loading conditions by percutaneous pulmonary valve implantation on exercise capacity. Am J Cardiol 2010; 105:721-6. [PMID: 20185023 DOI: 10.1016/j.amjcard.2009.10.054] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 10/28/2009] [Accepted: 10/28/2009] [Indexed: 02/01/2023]
Abstract
The data describing the change in exercise capacity after surgical or interventional management of the patient with right ventricular (RV) outflow tract (OT) dysfunction are conflicting. The pathophysiologic consequences of RVOT interventions and the subsequent change in exercise performance are still poorly understood. We sought to assess the effect of percutaneous pulmonary valve implantation (PPVI) on exercise capacity in (1) patients with predominantly pulmonary stenosis (PS) and (2) in patients with predominantly pulmonary regurgitation (PR). A total of 63 patients with either predominantly PS (n = 37) or PR (n = 26) underwent PPVI. Cardiopulmonary exercise testing and magnetic resonance imaging were performed before and within 1 month after PPVI. On magnetic resonance imaging, the at rest effective biventricular stroke volumes improved in both groups after PPVI (p <0.001), but the ejection fraction improved only in the PS group. In the PS group, exercise capacity (peak oxygen uptake, p <0.001), ventilatory efficiency (p <0.001), and peak oxygen pulse (p <0.001) improved after PPVI. In the PR group, none of these parameters changed after PPVI (p = 0.6, p = 0.12, and p = 0.9, respectively). On multivariate analysis, the reduction in RVOT gradient was the only predictor of improved peak oxygen uptake when assessed in the whole patient group (r(part) = -0.59; p <0.001) or in the PS (r(part) = -0.45; p = 0.002) or PR groups alone (r(part) = -0.45; p = 0.02). In conclusion, acutely after PPVI, exercise capacity improves with the relief of stenosis but not regurgitation. A reduction in the RVOT gradient, even small gradients, was the only independent predictor of improved peak oxygen uptake in both patient groups, irrespective of improved pulmonary valve competence.
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Affiliation(s)
- Philipp Lurz
- Cardiovascular Unit, UCL Institute of Child Health and Cardiorespiratory Unit, Great Ormond Street Hospital for Children, London, UK.
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Lurz P, Bonhoeffer P, Taylor AM. Percutaneous pulmonary valve implantation: an update. Expert Rev Cardiovasc Ther 2009; 7:823-33. [PMID: 19589118 DOI: 10.1586/erc.09.57] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The field of percutaneous valvular interventions is one of the most exciting and rapidly developing within interventional cardiology. Percutaneous pulmonary valve implantation (PPVI) represents the first in-human application of these techniques and is a nonsurgical option for treating right ventricular outflow tract/pulmonary trunk dysfunction. With the growing numbers of patients with right ventricle to pulmonary artery conduit dysfunction after repair of congenital heart disease, the importance of a technique with lower morbidity and mortality, good patient acceptance and efficacy, that is comparable to surgery, cannot be underestimated. Over the last 9 years, PPVI has become a feasible, safe and effective treatment for both conduit stenosis and regurgitation. Median follow-up data show good freedom from reoperation and recatheterization and demonstrate that PPVI can postpone open-heart surgery, thereby potentially reducing the number of operations that patients have to undergo within their lifetime. Complications seen after PPVI, in particular stent fractures, can require reintervention in some cases (second stent-in-stent PPVI); however, valve competency remains good, with significant regurgitation during follow-up only seen in the context of occasional endocarditis. Attempts are now being made to prolong the lifespan of the device by reducing the incidence of stent fractures. Further, meticulous patient selection must be maintained to ensure that hemodynamic results are optimized and the safety of the procedure remains high. Finally, new devices have to be developed that will allow for PPVI in dilated, distensible outflow tracts, to offer this nonsurgical treatment option to a larger patient population with congenital heart disease.
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Affiliation(s)
- Philipp Lurz
- UCL Institute of Child Health and Great Ormond Street Hospital for Children, Cardiorespiratory Unit, London, UK.
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Affiliation(s)
- Daphne T. Hsu
- From the Division of Pediatric Cardiology (D.T.H.), Children’s Hospital at Montefiore and Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; and Heart Development and Structural Diseases Branch (G.D.P.), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Gail D. Pearson
- From the Division of Pediatric Cardiology (D.T.H.), Children’s Hospital at Montefiore and Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; and Heart Development and Structural Diseases Branch (G.D.P.), National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
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Right ventricular peak systolic longitudinal strain is a sensitive marker for right ventricular deterioration in adult patients with tetralogy of Fallot. Int J Cardiovasc Imaging 2009; 25:669-76. [PMID: 19642012 PMCID: PMC2729418 DOI: 10.1007/s10554-009-9477-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 07/09/2009] [Indexed: 11/26/2022]
Abstract
The aim of this study was to evaluate the feasibility of right ventricular (RV) longitudinal peak systolic strain (LPSS) assessment for the follow-up of adult patients with corrected tetralogy of Fallot (TOF). Adult patients (n = 18) with corrected TOF underwent echocardiography and CMR twice with a time interval of 4.2 ± 1.7 years. RV performance was derived from CMR, and included RV volumes and ejection fraction (EF). LPSS was calculated globally (GLPSS) and in the RV free wall (LPSS FW), with echocardiographic speckle-tracking strain-analysis. Baseline (G)LPSS values were compared between patients and healthy controls; the relation between (G)LPSS and CMR parameters was evaluated and the changes in (G)LPSS and CMR parameters during follow-up were compared. GLPSS and LPSS FW were significantly reduced in patients as compared to controls (−14.9 ± 0.7% vs. −21.6 ± 0.9% and −15.5 ± 0.9% vs. −22.7 ± 1.5%, P < 0.01). Moderate agreement between LPSS and CMR parameters was observed. RV EF remained unchanged during follow-up, whereas GLPSS and LPSS FW demonstrated a significant reduction. RVEF showed a 1% increase, whereas GLPSS decreased by 14%, and LPSS FW by 27%. RV LPSS is reduced in TOF patients as compared to controls; during follow-up RV EF remained unchanged whereas LPSS decreased suggesting that RV LPSS may be a sensitive marker to detect early deterioration in RV performance.
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Marcotte F, Poirier N, Pressacco J, Paquet É, Mercier LA, Dore A, Ibrahim R, Khairy P. Evaluation of Adult Congenital Heart Disease by Cardiac Magnetic Resonance Imaging. CONGENIT HEART DIS 2009; 4:216-30. [DOI: 10.1111/j.1747-0803.2009.00313.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Tetralogy of Fallot is a congenital cardiac malformation that consists of an interventricular communication, also known as a ventricular septal defect, obstruction of the right ventricular outflow tract, override of the ventricular septum by the aortic root, and right ventricular hypertrophy. This combination of lesions occurs in 3 of every 10,000 live births, and accounts for 7-10% of all congenital cardiac malformations. Patients nowadays usually present as neonates, with cyanosis of varying intensity based on the degree of obstruction to flow of blood to the lungs. The aetiology is multifactorial, but reported associations include untreated maternal diabetes, phenylketonuria, and intake of retinoic acid. Associated chromosomal anomalies can include trisomies 21, 18, and 13, but recent experience points to the much more frequent association of microdeletions of chromosome 22. The risk of recurrence in families is 3%. Useful diagnostic tests are the chest radiograph, electrocardiogram, and echocardiogram. The echocardiogram establishes the definitive diagnosis, and usually provides sufficient information for planning of treatment, which is surgical. Approximately half of patients are now diagnosed antenatally. Differential diagnosis includes primary pulmonary causes of cyanosis, along with other cyanotic heart lesions, such as critical pulmonary stenosis and transposed arterial trunks. Neonates who present with ductal-dependent flow to the lungs will receive prostaglandins to maintain ductal patency until surgical intervention is performed. Initial intervention may be palliative, such as surgical creation of a systemic-to-pulmonary arterial shunt, but the trend in centres of excellence is increasingly towards neonatal complete repair. Centres that undertake neonatal palliation will perform the complete repair at the age of 4 to 6 months. Follow-up in patients born 30 years ago shows a rate of survival greater than 85%. Chronic issues that now face such adults include pulmonary regurgitation, recurrence of pulmonary stenosis, and ventricular arrhythmias. As the strategies for surgical and medical management have progressed, the morbidity and mortality of those born with tetralogy of Fallot in the current era is expected to be significantly improved.
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Affiliation(s)
- Frederique Bailliard
- North Carolina Children's Heart Center, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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Abstract
Tetralogy of Fallot is a congenital cardiac malformation that consists of an interventricular communication, also known as a ventricular septal defect, obstruction of the right ventricular outflow tract, override of the ventricular septum by the aortic root, and right ventricular hypertrophy. This combination of lesions occurs in 3 of every 10,000 live births, and accounts for 7-10% of all congenital cardiac malformations. Patients nowadays usually present as neonates, with cyanosis of varying intensity based on the degree of obstruction to flow of blood to the lungs. The aetiology is multifactorial, but reported associations include untreated maternal diabetes, phenylketonuria, and intake of retinoic acid. Associated chromosomal anomalies can include trisomies 21, 18, and 13, but recent experience points to the much more frequent association of microdeletions of chromosome 22. The risk of recurrence in families is 3%. Useful diagnostic tests are the chest radiograph, electrocardiogram, and echocardiogram. The echocardiogram establishes the definitive diagnosis, and usually provides sufficient information for planning of treatment, which is surgical. Approximately half of patients are now diagnosed antenatally. Differential diagnosis includes primary pulmonary causes of cyanosis, along with other cyanotic heart lesions, such as critical pulmonary stenosis and transposed arterial trunks. Neonates who present with ductal-dependent flow to the lungs will receive prostaglandins to maintain ductal patency until surgical intervention is performed. Initial intervention may be palliative, such as surgical creation of a systemic-to-pulmonary arterial shunt, but the trend in centres of excellence is increasingly towards neonatal complete repair. Centres that undertake neonatal palliation will perform the complete repair at the age of 4 to 6 months. Follow-up in patients born 30 years ago shows a rate of survival greater than 85%. Chronic issues that now face such adults include pulmonary regurgitation, recurrence of pulmonary stenosis, and ventricular arrhythmias. As the strategies for surgical and medical management have progressed, the morbidity and mortality of those born with tetralogy of Fallot in the current era is expected to be significantly improved.
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Affiliation(s)
- Frederique Bailliard
- North Carolina Children's Heart Center, Department of Pediatrics, University of North Carolina at Chapel Hill, USA
| | - Robert H Anderson
- North Carolina Children's Heart Center, Department of Pediatrics, University of North Carolina at Chapel Hill, USA
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
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