Functional health status in adult survivors of operative repair of tetralogy of fallot

Evolution of Right Ventricular Electromechanical Dyssynchrony During Childhood After Tetralogy of Fallot Repair

BACKGROUND

Patients with repaired tetralogy of Fallot (rTOF) develop electromechanical dyssynchrony (EMD), which detrimentally affects right ventricular (RV) function and exercise capacity. However, EMD evolution over childhood is unknown.

METHODS

We retrospectively studied serial ECG, Holter, echocardiography, cardiac magnetic resonance, and exercise data of rTOF patients, over the first 18-years of life, who underwent repair from 2010 to 2020. Mechanical dyssynchrony parameters were evaluated at ages 8-12 and 14-18 years.

RESULTS

A total of 95 patients (61% male) were followed for a median 15.7 years (range 8-18 years). QRS duration (QRSd) increased steeply in the first 6 years and gradually through adolescence. Prolonged QRSd was associated with decreased VO2 (P = 0.001), peak workload (P = 0.008), and RV ejection fraction (RVEF). RVEF decreased by 1.3% (-0.7 to -1.9) for every 10 ms increase in QRSd (P < 0.001). Patients with QRSd z score > 2 had a declining RVEF, despite a stable pulmonary insufficiency fraction and indexed RV end-diastolic volume throughout childhood. QRS fractionation (fQRS) increased during the first 6 years and then again in adolescence, which temporally coincided with the onset of arrhythmias. fQRS was associated with decreased RVEF (odds ratio [OR] 0.94; 95% confidence interval [CI] 0.9-1; P = 0.05) and RV longitudinal strain (OR 1.02; 95% CI 1.01-1.04; P = 0.008). 70.5% of patients had a septal flash at the first mechanical dyssynchrony assessment, which was associated with longer QRSd (median 124 ms [interquartile range (IQR) 107-136 ms] vs 100 ms [IQR 93-118 ms]; P = 0.019).

CONCLUSIONS

Electrical dyssynchrony is associated with progressive RV dysfunction and exercise intolerance over the course of childhood in rTOF, independently from pulmonary insufficiency. This raises the question of considering RV resynchronisation therapy in selected patients with symptomatic RV dysfunction and EMD.

Pulmonary and tricuspid regurgitation after Tetralogy of Fallot repair: A case report

BACKGROUND

Tetralogy of Fallot (TOF) is one of the most common congenital heart defects, and surgery is the primary treatment. There are no precise guidelines on the treatment protocol for tricuspid regurgitation (TR) as a common complication of TOF repair. The timing for treatment in patients presenting with valve regurgitation after TOF repair is often difficult to determine. Here, we report the first case of sequential treatment of pulmonary and TR using interventional therapy.

CASE SUMMARY

We present the case of a 52-year-old female patient, who had a history of TOF repair at a young age. A few years later, the patient presented with pulmonary and tricuspid regurgitation. The symptoms persisted and TR worsened following percutaneous pulmonary valve implantation. Preoperative testing revealed that the patient's disease had advanced to an intermediate to advanced stage and that her general health was precarious. Because open-heart surgery was not an option for the patient, transcatheter tricuspid valve replacement was suggested. This procedure was successful, and the patient recovered fully without any adverse effects. This case report may serve as a useful resource for planning future treatments.

CONCLUSION

Treatment of both valves should be considered in patients with tricuspid and pulmonary regurgitations following TOF repair. The interventional strategy could be an alternative for patients with poor general health.

Electromechanical Dyssynchrony Is Associated With Right Ventricular Remodeling and Dysfunction Independently of Pulmonary Regurgitation Late After Tetralogy of Fallot Repair

BACKGROUND

The aim of this study was to investigate the relationship among right ventricular (RV) dilatation, dysfunction, and electromechanical dyssynchrony (EMD) in patients with repaired tetralogy of Fallot (rTOF).

METHODS

Data from a prospective rTOF registry of subjects with moderate or greater pulmonary regurgitation (PR) and contemporary imaging were analyzed. Electrocardiograms and echocardiograms were analyzed for EMD (prolonged QRS duration [QRSd], echocardiographic septal flash, and mechanical delay) and mechanical dispersion. The relationship among these, RV measurements on cardiac magnetic resonance, exercise capacity, and incident arrhythmia or death was analyzed with adjustment for PR.

RESULTS

In total, 271 patients with rTOF (42% women; median age, 32 years; interquartile range [IQR], 23-34 years) were included. Patients had moderate to severe PR (median PR fraction, 38%; IQR, 30%-47%), moderate to severe RV enlargement (median RV end-diastolic volume index, 161 mL/m2; IQR, 138-186 mL/m2) and mild RV systolic dysfunction (median RV ejection fraction [RVEF], 44%; IQR, 38%-48%). Eleven patients (4%) experienced ventricular arrhythmia or death. Presence of EMD was associated with larger RV size (RV end-diastolic volume index and RV end-systolic volume index, P = .006 and P < .001, respectively) and lower RVEF (P < .001). A sharp inflection in the relation among QRSd, RV size, and RVEF was observed when QRSd exceeded 150 msec (3.1% decrease in RVEF for every 20-msec increase in QRSd between 160 and 200 msec). Similar inflection points were observed for the mechanical delay between the RV basal-lateral and midseptal segments. The mechanical delay was higher in patients with vs without incident atrial arrhythmia (371 vs 276 msec, P = .014).

CONCLUSIONS

In adults with rTOF, EMD is independently associated with larger RV size, lower RVEF, and incident atrial arrhythmias.

Physical Activity Promotion Among Individuals With Tetralogy of Fallot

In the general population, the most cited barriers to physical activity (PA) are time, energy, and motivation. Consequently, despite the significant contribution of PA to health and well-being, many individuals are insufficiently active. Physical inactivity and sedentary lifestyles increase the risk of acquired cardiometabolic disease, a risk that may complicate and is compounded by the anatomic and physiologic features inherent in the patient with repaired tetralogy of Fallot (ToF). Individuals with ToF commonly present with reduced exercise capacity and PA levels. In light of historically PA restrictive management of their heart disease, known reductions in exercise capacity among individuals with ToF are combined with psychosocial barriers to their participation, potentially establishing a cycle of further detraining, inactivity, and disease progression/health decline. To this end, children and young adults with ToF are known to have reduced self-efficacy towards PA, defined as their confidence in their ability to participate. In this review, we apply self-efficacy as an overarching mediator of PA participation and explore trends and determinants of PA participation among individuals with ToF and its subsequent impact on exercise capacity, disease risk, and health-related quality of life. We outline the rationale and strategies aimed at improving PA in children and adults with ToF and highlight current knowledge gaps and future directions in the promotion of PA in the population with ToF.

Health related quality of life in adults after late repair of tetralogy of fallot: experience from a low-middle income country

PURPOSE

Without neonatal screening in low middle-income countries like Pakistan, Tetralogy of Fallot (TOF) is a congenital heart disease which frequently remains untreated beyond infancy. The purpose of this study is to determine and assess outcomes and health related quality of life (HRQOL) in patients who undergo complete repair of TOF as adults.

METHODS

56 patients who underwent complete TOF repair after 16 years of age were included. Patient data was collected via retrospective chart review, and a semi structured interview along with Short-Form 36 (SF-36) questionnaire were used to assess HRQOL.

RESULTS

66.1% of patients were male with the mean age at surgery of 22.3 ± 6.00. All patients had a post-operative NYHA Classification of I or II, 94.6% had an ejection fraction of ≥ 50% and 28.6% showed small residual lesions in follow-up echocardiograms. 32.1% of patients suffered post-operative morbidity. For the quantitative assessment using SF-36 scores, patients showed good scores of median 95 (65-100). A major cause of delay to treatment was lack of consensus between treatments offered by doctors in different parts of Pakistan. There was a pattern of 'inability to fit in' among patients who had had late TOF repair, despite self- reported improved HRQOL.

CONCLUSION

Our results indicate that even with a delayed diagnosis, surgical repair of TOF produces good functional results. However, these patients face significant psychosocial issues. While early diagnosis remains the ultimate goal, patients undergoing late repair should be managed in more holistic manner with attention to psychological impact of the disease as well.

Patient-Reported Outcomes After Tetralogy of Fallot Repair

BACKGROUND

Comprehensive assessment of tetralogy of Fallot (TOF) outcomes extends beyond morbidity and mortality to incorporate patient-reported outcomes (PROs), including quality of life (QOL) and health status (HS).

OBJECTIVES

This study explored PROs in adolescents and adults with TOF and delineated variables associated with PROs.

METHODS

This was a cross-sectional observational study within a larger prospective registry of adolescents and adults with repaired TOF and moderate or greater pulmonary regurgitation from North America, Europe, and Asia. Participants completed PROs, including a QOL linear analogue scale (QOL-LAS) and an HS visual analogue scale (HS-VAS). Scores were classified according to age cohorts: <18, 18 to 25, 26 to 40, and >40 years.

RESULTS

The study included 607 patients (46.3% female; median age 28.5 years). Median QOL-LAS scores (0-100) were similar across age cohorts (85, 80, 80, 80; P = 0.056). Median HS-VAS scores (0-100) were lowest for the oldest cohort (77) compared with the 3 younger cohorts (85, 80, 80) (P = 0.004). With advancing age, there were increased reports of poor mobility (P < 0.001) and pain or discomfort (P = 0.004); problems in these dimensions were reported by 19.1% and 37.2% of patients aged >40 years, respectively. Of factors associated with superior PROs on multivariable regression modeling (ie, being White, being nonsyndromic, having employment, and having better left ventricular function; P < 0.05), asymptomatic status (functional class I) was the variable associated with the greatest number of QOL and HS measures (P < 0.001).

CONCLUSIONS

Strategies to improve TOF outcomes should consider PROs alongside conventional clinical variables. Factors associated with poorer PROs represent opportunities to intervene to improve the lives of patients with TOF.

Quality of life among adults with repaired tetralogy of fallot: A literature review

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect. Survival into adulthood is currently expected following surgical repair, leading to a growing population of adults with repaired TOF. In this literature review, we aim to summarize the current state of knowledge on the quality of life of adults with repaired TOF. A search was conducted on PubMed and results were reviewed for articles published between January of 2010 and June of 2020. Search terms included "Tetralogy of Fallot", "repaired", "adults" and "quality of life". For the subjective health status evaluation, most published studies used Short-Form-36. Most studies agree that physical complex status is poorer for adult patients with repaired TOF than for controls. Mental complex status was also lower. Patients reported similar satisfaction with their lives and levels of social participation. Most patients had a college or university degree. Higher education, male gender and having a partner were positively associated with being employed. Studies found no difference in the proportion of patients that are married or living with a partner, compared to control groups. Patients operated for TOF have a lower reproduction rate compared with the background population. A consistent finding of these studies is abnormal physical parameters compared to psychosocial issues. The diverse needs of adults with repaired TOF require a multidisciplinary care, that takes into consideration all aspects that affect their quality of life. Despite abnormal physical functional status, it is reassuring that most adult patients with TOF lead independent and productive lives.

Health-related quality of life in adults with tetralogy of Fallot repair: a systematic review and meta-analysis

BACKGROUND

With the advancement in diagnostics and clinical management, patients with Tetralogy of Fallot (ToF) are surviving till adulthood. Hence, assessing the impact of ToF repair on health-related quality of life (HRQOL) of these patients is becoming increasingly important. The objective of this paper is to conduct a systematic review and meta-analysis of the HRQOL in patients who have undergone ToF repair.

METHODS

A systematic search was conducted using PubMed, CINAHL, Medline and Web of Science databases. Studies that compared the HRQOL of adult patients (mean age ≥ 18 years) who had previously undergone ToF repair with healthy controls were included. Analysis was done via Revman V5.3 using a random effects model.

RESULTS

The 16 studies (15 using SF-36) included in the meta-analysis, comprised 1818 patients and 50,265 healthy controls. There was a higher proportion of males (59%). The mean ages at surgery and at HRQOL assessment were 5.37 years and 30.3 years, respectively. We found that repaired ToF patients had a statistically significantly lower score in the physical component summary (SMD = - 0.92 CI = - 1.54, - 0.30) and physical functioning (SMD = - 0.27 CI = - 0.50, - 0.03) compared to healthy controls. However, these patients had statistically significantly higher scores in the bodily pain domain (SMD = 0.35 CI = 0.12, 0.58) and social functioning (SMD = 0.23 CI = 0.01, 0.46), while there was no significant difference in other domains.

CONCLUSION

Overall, physical domain of HRQOL was statistically significantly lower in repaired ToF patients compared to healthy controls. However, repaired ToF patients scored significantly higher on bodily pain and Social Functioning. There was additionally no difference in the HRQOL between the two groups in other domains of HRQOL.

How pulmonary valve regurgitation after tetralogy of fallot repair changes the flow dynamics in the right ventricle: An in vitro study

Tetralogy of Fallot is the most common cyanotic congenital disease, affecting 10% of children with congenital heart disease. The surgical management of patients with Tetralogy of Fallot leads, however, to significant detrimental effects on the right ventricle including pulmonary valve regurgitation. This experiment aimed to simulate different cases of pulmonary valve regurgitation with varying degrees of severity in order to observe the changes in flow structures present in the right ventricle. Planar time-resolved particle image velocimetry measurements have been performed on a custom-made double activation simulator reproducing flow conditions in a model of a right ventricle. Changes in flow characteristics in the right ventricle have been evaluated in terms of velocity fields and profiles, tricuspid inflow jet orientation and viscous energy dissipation. Our results show that pulmonary valve regurgitation significantly alters the flow in the right ventricle mostly by impairing the diastolic inflow through the tricuspid valve and by increasing viscous energy loss. This fundamental work should allow for a better understanding of such changes in the RV flow dynamics. It may also help in developing new strategies allowing for a better follow-up of patients with repaired TOF and for decision-making in terms of pulmonary valve replacement.

Spectrum of changes on cardiac magnetic resonance in repaired tetralogy of Fallot: Imaging according to surgical considerations

Imaging of repaired tetralogy of Fallot (TOF) is one of the common indications for cardiac magnetic resonance (CMR) examinations. With advances in CMR imaging techniques like phase contrast imaging and functional imaging, it has superseded investigations like echocardiography for anatomical and functional assessment of the pathophysiological changes in repaired TOF. Common repair procedures for TOF include infundibulectomy, transannular patch repair and right ventricle to pulmonary artery (RV-PA) conduit. While each of these procedures cause dynamic changes in heart and pulmonary arteries resulting in some expected imaging findings, CMR also helps in diagnosing the complications associated with these repair procedures like pulmonary stenosis, right ventricular outflow tract aneurysm, pulmonary regurgitation, RV-PA conduit stenosis, tricuspid regurgitation, right ventricular failure, and residual ventricular septal defects. Hence, it is imperative for a radiologist to be familiar with the expected changes on CMR in repaired TOF along with some of the common complications that may be encountered on imaging in such patients.

The TRIVIA Cohort for Surgical Management of Tetralogy of Fallot: Merging Population and Clinical Data for Real-World Scientific Evidence

Background

Guidelines for surgical management of tetralogy of Fallot (TOF) are often based on low-quality evidence due to the many challenges of congenital heart disease: heterogeneous cardiac anatomy, consequences from surgical interventions arising years later, and scarcity of hard outcomes. The overarching goal of the Tetralogy of Fallot Research for Improvement of Valve replacement Intervention: A Bridge Across the Knowledge Gap (TRIVIA) study is to evaluate the long-term impact of the surgical management strategies in TOF. The specific objectives are: (1) to describe the long-term outcomes of TOF according to the native anatomy and the presence of genetic conditions, (2) to evaluate the long-term outcomes of surgical repair according to associated residual lesions, and (3) to evaluate the impact of paediatric pulmonary valve replacements on the long-term outcomes.

Methods

The TRIVIA study is a population-based cohort including all subjects with TOF in the province of Québec between 1980 and 2017. It links patient-level granular clinical data with long-term administrative health care data. We will evaluate mortality, cardiovascular interventions, and hospitalizations for adverse cardiovascular events using survival Cox models and marginal mean/rates models for recurrent events, respectively. Multivariate multilevel models will correct for potential confounders, and risk score matching will mitigate the potential of confounding by indication.

Results

The current TRIVIA cohort includes 1001 eligible subjects with TOF with complete lifelong follow-up for > 98%. The median follow-up is 17.1 years, totalling > 17,000 patient-years.

Conclusions

Universal health insurance data combined with granular clinical data enable the development of population-based cohorts, to which contemporary statistical methods are applied to address important research questions in congenital heart disease research.

Implementation of Quality-of-Life Assessment Increases Referrals for Intervention in Patients with Tetralogy of Fallot

Mortality from surgical repair of tetralogy of Fallot (TOF) has decreased dramatically over the last several decades. Despite excellent surgical outcomes, studies reveal that patients with TOF continue to have decreased physical functioning, academic difficulties, and psychosocial impairments. We hypothesized that administering a validated quality-of-life assessment to patients with TOF during routine cardiology follow-up visits would help identify deficits and increase referrals to appropriate interventional programs. Between May 2017 and November 2018, TOF patients (5-20 years) and/or their families completed a standardized quality-of-life assessment (PedsQL 4.0) during cardiology clinic visits. Providers were encouraged to refer patients with abnormal PedsQL 4.0 scores to appropriate services including cardiovascular rehabilitation, psychological evaluation, neurodevelopmental testing, and school intervention. Referrals for the intervention group were compared to those of a control group using χ² analysis. The PedsQL 4.0 was completed by 79 patients at 90 clinic visits. At least one abnormal PedsQL 4.0 score was identified in 58% (52/90) of patient encounters, and of those 52 encounters, 38% (20/52) received at least one referral for intervention. The most commonly placed referrals were for neurodevelopmental testing (16) and school intervention (11). When comparing the number of referrals from the intervention group to those of the control group, referrals to all intervention services were statistically significant (p < 0.05). Our quality improvement initiative successfully utilized a quality-of-life assessment to detect deficits and subsequently increased the number of referrals to intervention services. Future studies will address barriers that prevent completion of the PedsQL and assess how interventions impact quality-of-life scores.

A Review of Tetralogy of Fallot and Postoperative Management

This article discusses the anatomy and physiology of tetralogy of Fallot (TOF) and TOF variants. Indications for surgical repair, morbidity/mortalities, and surgical repair techniques are also reviewed. The article concludes with review of common postoperative complications and management strategies for arrhythmias, right ventricular dysfunction, low cardiac output, and residual defects.

Factors associated with health-related quality of life among adults with tetralogy of Fallot

Background

Due to improved care, the numbers of patients with tetralogy of Fallot (ToF) are increasing. However, long-term morbidity and need for reinterventions are concerns and also address issues of quality of life (QoL).

Methods

Patients with ToF and valid EuroQol-5 dimensions questionnaire (EQ-5D) were identified in the national Swedish register on congenital heart disease. EQ-5D_index was calculated and dichotomised into best possible health-related QoL (EQ-5D_index=1) or differed from 1.

Results

288 patients met the criteria and were analysed. Univariate logistic regression showed a positive association between New York Heart Association (NYHA) class I (OR 8.32, 95% CI 3.80 to 18.21), physical activity >3 h/week (OR 3.34, 95% CI 1.67 to 6.66) and a better right ventricular function (OR 2.56, 95% CI 1.09 to 6.02). A negative association between symptoms (OR 0.23, 95% CI 0.13 to 0.42), cardiovascular medication (OR 0.31, 95% CI 0.18 to 0.53), age (OR 0.97, 95% CI 0.96 to 0.99) and EQ-5D_index was observed. In multivariate logistic regression, NYHA I (OR 7.28, 95% CI 3.29 to 16.12) and physical activity >3 h/week (OR 2.27, 95% CI 1.07 to 4.84) remained associated with best possible health-related QoL. Replacing NYHA with symptoms in the model yielded similar results.

Conclusion

In this registry study, self-reported physical activity, staff-reported NYHA class and absence of symptoms were strongly associated with best possible health-related QoL measured by EQ-5D. Physical activity level is a potential target for intervention to improve QoL in this population but randomised trials are needed to test such a hypothesis.

4-D flow magnetic-resonance-imaging-derived energetic biomarkers are abnormal in children with repaired tetralogy of Fallot and associated with disease severity

BACKGROUND

Cardiac MRI plays a central role in monitoring children with repaired tetralogy of Fallot (TOF) for long-term complications. Current risk assessment is based on volumetric and functional parameters that measure late expression of underlying physiological changes. Emerging 4-D flow MRI techniques promise new insights.

OBJECTIVE

To assess whether 4-D flow MRI-derived measures of blood kinetic energy (1) differentiate children and young adults with TOF from controls and (2) are associated with disease severity.

MATERIALS AND METHODS

Pediatric patients post TOF repair (n=21) and controls (n=24) underwent 4-D flow MRI for assessment of time-resolved 3-D blood flow. Data analysis included 3-D segmentation of the right ventricle (RV) and pulmonary artery (PA), with calculation of peak systolic and diastolic kinetic energy (KE) maps. Total KE_RV and KE_PA were determined from the sum of the KE of all voxels within the respective time-resolved segmentations.

RESULTS

KE_PA was increased in children post TOF vs. controls across the cardiac cycle, with median 12.5 (interquartile range [IQR] 10.3) mJ/m² vs. 8.2 (4.3) mJ/m², P<0.01 in systole; and 2.3 (2.7) mJ/m² vs. 1.4 (0.9) mJ/m², P<0.01 in diastole. Diastolic KE_PA correlated with systolic KE_PA (R² 0.41, P<0.01) and with pulmonary regurgitation fraction (R² 0.65, P<0.01). Diastolic KE_RV showed similar relationships, denoting increasing KE with higher cardiac outputs and increased right heart volume loading. Diastolic KE_RV and KE_PA increased with RV end-diastolic volume in a non-linear relationship (R² 0.33, P<0.01 and R² 0.50, P<0.01 respectively), with an inflection point near 120 mL/m².

CONCLUSION

Four-dimensional flow-derived KE is abnormal in pediatric patients post TOF repair compared to controls and has a direct, non-linear relationship with traditional measures of disease progression. Future longitudinal studies are needed to evaluate utility for early outcome prediction in TOF.

Self-reported functional health status following interrupted aortic arch repair: A Congenital Heart Surgeons' Society Study

OBJECTIVES

Improved survival after congenital heart surgery has led to interest in functional health status. We sought to identify factors associated with self-reported functional health status in adolescents and young adults with repaired interrupted aortic arch.

METHODS

Follow-up of survivors (aged 13-24 years) from a 1987 to 1997 inception cohort of neonates included completion of functional health status questionnaires (Child Health Questionnaire-CF87 [age <18 years, n = 51] or the Short Form [SF]-36 [age ≥18 years, n = 66]) and another about 22q11 deletion syndrome (22q11DS) features (n = 141). Factors associated with functional health status domains were determined using multivariable linear regression analysis.

RESULTS

Domain scores of respondents were significantly greater than norms in 2 of 9 Child Health Questionnaire-CF87 and 4 of 10 SF-36 domains and only lower in the physical functioning domain of the SF-36. Factors most commonly associated with lower scores included those suggestive of 22q11DS (low calcium levels, recurrent childhood infections, genetic testing/diagnosis, abnormal facial features, hearing deficits), the presence of self-reported behavioral and mental health problems, and a greater number of procedures. Factors explained between 10% and 70% of domain score variability (R² = 0.10-0.70, adj-R² = 0.09-0.66). Of note, morphology and repair type had a minor contribution.

CONCLUSIONS

Morbidities associated with 22q11DS, psychosocial issues, and recurrent medical issues affect functional health status more than initial morphology and repair in this population. Nonetheless, these patients largely perceive themselves as better than their peers. This demonstrates the chronic nature of interrupted aortic arch and suggests the need for strategies to decrease reinterventions and for evaluation of mental health and genetic issues to manage associated deteriorations.

Right Heart-Pulmonary Circulation Unit in Congenital Heart Diseases

The right ventricle plays a major role in congenital heart disease. This article describes the right ventricular mechanics in some selected congenital heart diseases affecting the right ventricle in different ways: tetralogy of Fallot, Ebstein anomaly, and the systemic right ventricle.

Quality of life in adults with repaired tetralogy of Fallot

Introduction

Observations of patients after repair of tetralogy of Fallot (ToF) indicate good correction results and long-term survival. Few papers have been published in which the quality of life (QoL) of this population has been assessed.

Aim

To evaluate QoL in adults with repaired ToF.


Material and methods

We included 39 patients with repaired ToF and 40 age- and sex-matched healthy volunteers. Information recorded included echocardiography, cardiac magnetic resonance, cardiopulmonary exercise test, and self-reported health-related QoL questionnaire (SF-36).


Results

The perceived physical and mental domains of health were signi cantly poorer in ToF patients than in controls. A positive correlation between VO₂ peak and physical domains was observed: (VO₂ peak vs. physical domains (r = 0.6, p ≤ 0.001), general health (r = 0.36, p = 0.03), and physical complex status (r = 0.51, p = 0.001). VO₂ peak % correlated with physical functioning (r = 0.43, p = 0.007), general health (r = 0.39, p = 0.015) and physical complex status (r = 0.49, p = 0.002). Right ventricle ejection fraction, determined with cardiac magnetic resonance, positively correlated with role physical (r = 0.38, p = 0.04). In echocardiography, pressure half time was posi- tively correlated with physical functioning (r = 0.48, p = 0.004) and role physical (r = 0.4, p = 0.02).


Conclusions

The QoL in adults after repair of ToF and healthy control subjects was compared directly. The self-perceived physical and mental domains of health were significantly poorer in ToF patients than in controls. Strong associations were found between objective exercise capacity and physical aspects of quality of life. Complex assessment and quality of life instruments should be used together to obtain an accurate view of health status of patients with repaired ToF.

Quality of Life is Diminished in Patients with Tetralogy of Fallot with Mild Residual Disease: A Comparison of Tetralogy of Fallot and Isolated Valvar Pulmonary Stenosis

The objective of this study is to compare quality of life (QOL) in patients with mild pulmonary insufficiency (PI) after Tetralogy of Fallot (TOF) repair or after balloon dilation for isolated valvar pulmonary stenosis (VPS). A cross-sectional study of patients with TOF (n = 12) and VPS (n = 19), ages 8-18 years, who underwent cardiac magnetic resonance (CMR) and cardiopulmonary exercise test (CPET) was conducted. Patients with genetic syndromes were excluded. The groups were matched by severity and duration of PI using propensity scores. PI was greater than mild if the regurgitant fraction by CMR was >20%. Health status and QOL assessment included Child Health Questionnaire Child Self-Report (CHQ-CF87), Child Health Questionnaire Parent Report (CHQ-PF50), and Pediatric Cardiac QOL Instrument (parent and patient). QOL scores were compared between groups. Due to propensity matching, the groups had, at worst, mild PI and normal right ventricular ejection fraction on CMR. Parental perception of QOL was significantly worse in TOF as compared to VPS in the domains of general perception of health (P = 0.03), physical functioning (PF; P = 0.004), and family cohesion (P = 0.048). There were no differences in self-reported QOL between groups. There was no association between QOL and right ventricular function on CMR or percent-predicted maximal oxygen consumption on CPET in both groups. Parent-perceived QOL, in the domains of general health perception, PF, and family cohesion, is significantly reduced in patients with TOF with mild residual disease suggesting that the psychosocial impact of congenital heart disease may be significant even with successful repair and satisfactory medical status.

Exercise Performance and 22q11.2 Deletion Status Affect Quality of Life in Tetralogy of Fallot

OBJECTIVE

To identify mediators of health status and quality of life (QOL) in children and adolescents aged 8-18 years old following surgical repair for tetralogy of Fallot (TOF), including resource use, exercise performance, and 22q11.2 deletion status.

STUDY DESIGN

We performed a corollary study to a cross-sectional analysis of subjects following repair for TOF that completed cardiac magnetic resonance imaging, cardiopulmonary exercise tests, and instruments assessing health status and QOL. General linear models were used to test for mediation.

RESULTS

A total of 29 of 151 (19%) patients carried a 22q11.2 deletion. Parents of children with a deletion compared with those without a deletion reported worse physical and psychosocial functioning on the Child Health Questionnaire. The patients with a 22q11.2 deletion and their parents reported lower total and Disease Impact scores compared with the group without a deletion on the Pediatric Cardiac Quality of Life Inventory. Medical care use negatively correlated with measures of health status/QOL. Greater maximum work correlated with better patient health status and QOL, regardless of deletion status. Exercise performance mediated the association between deletion status and parent-reported outcomes (unstandardized effects ranging from 2.4 to 4.2) and patient-reported Disease Impact (0.99; 95% CI 0.02-2.70).

CONCLUSION

Children and adolescents following repair for TOF seem to suffer significant challenges to their health status and QOL, which is amplified markedly in the context of the 22q11.2 deletion syndrome, and related to exercise performance.

Patient outcomes after transcatheter and surgical pulmonary valve replacement for pulmonary regurgitation in patients with repaired tetralogy of Fallot: A quasi-meta-analysis

BACKGROUND

Individuals with repaired tetralogy of Fallot develop pulmonary regurgitation that may cause symptoms (dyspnea, chest pain, palpitations, fatigue, presyncope, and syncope), impair functional capacity, and may affect health-related quality of life. Surgical pulmonary valve replacement is the gold standard of treatment although transcatheter pulmonary valve replacement is becoming more common. Patients want to know whether less invasive options are as good.

AIMS

This analysis aimed to examine the differences in surgical versus transcatheter pulmonary valve replacement effects in terms of physiological/biological variables, symptoms, functional status and health-related quality of life.

METHODS

This quasi-meta-analysis included 85 surgical and 47 transcatheter pulmonary valve replacement studies published between 1995-2016.

RESULTS

In terms of physiological/biological variables, both surgical and transcatheter pulmonary valve replacement improved pulmonary regurgitation and systolic and diastolic right ventricular volume indices but not heart function. In the left heart, only surgical pulmonary valve replacement improved heart function. Only transcatheter pulmonary valve replacement improved left ventricular end-diastolic indices and neither improved endsystolic indices. Only surgery has been demonstrated to decrease QRS duration but there is little evidence of arrhythmia reduction. Symptom change is poorly documented. Functional class improves but exercise capacity generally does not. Some aspects of health-related quality of life improve with surgery and in one small transcatheter pulmonary valve replacement study.

CONCLUSION

Transcatheter and surgical pulmonary valve replacement compare favorably for heart remodeling. Exercise capacity does not change with either technique. Health-related quality of life improves after surgical pulmonary valve replacement. There are numerous gaps in documentation of changes in arrhythmias and symptoms.

Increased left ventricular myocardial extracellular volume is associated with longer cardiopulmonary bypass times, biventricular enlargement and reduced exercise tolerance in children after repair of Tetralogy of Fallot

BACKGROUND

Unfavorable left ventricular (LV) remodelling may be associated with adverse outcomes after Tetralogy of Fallot (TOF) repair. We sought to assess T1 cardiovascular magnetic resonance (CMR) markers of diffuse LV myocardial fibrosis in children after TOF repair, and associated factors.

METHODS

In this prospective, cross-sectional study, native (=non-contrast) T1 times and extracellular volume fraction (ECV) were quantified in the LV myocardium using CMR. Results were related to ventricular volumes and function, degree of pulmonary regurgitation, as well as surgical characteristics, and exercise capacity.

RESULTS

There was no difference in native T1 times or ECV between 31 TOF patients (age at CMR 13.9 ± 2.4 years, 19 male) and 15 controls (age at CMR 13.4 ± 2.6 years, 7 male). Female TOF patients had higher ECVs than males (25.2 ± 2.9 % versus 22.7 ± 3.3 %, p < 0.05). In the patient group, higher native T1 and ECV correlated with higher Z-Scores of right and left ventricular end-diastolic volumes, but not with reduced left and right ventricular ejection fraction or higher pulmonary regurgitation fraction. Longer cardiopulmonary bypass and aortic cross clamp times at surgery correlated with increased native T1 times and ECVs (r = 0.48, p < 0.05 and r = 0.65, p < 0.01, respectively). Maximum workload (percent of predicted for normal) correlated inversely with ECV (r = -0.62, p < 0.05). Higher native T1 times correlated with worse LV longitudinal (r = 0.50, p < 0.05) and mid short axis circumferential strain (r = 0.38, p < 0.05).

CONCLUSIONS

As compared to controls, TOF patients did not express higher markers of diffuse fibrosis. Longer cardiopulmonary bypass and aortic cross clamp times at surgery as well as biventricular enlargement and reduced exercise tolerance are associated with markers of diffuse myocardial fibrosis after TOF repair. Female patients have higher markers of diffuse myocardial fibrosis than males.

Predictors of Change in Functional Health Status in Adults with Repaired Tetralogy of Fallot

Left ventricular (LV) ejection fraction (EF) and right ventricular (RV) ejection fraction by cardiovascular magnetic resonance (CMR) are associated with functional health status in patients with repaired tetralogy of Fallot (TOF) in cross-sectional studies, but few longitudinal data are available. This study aimed to determine predictors of subsequent decrease in functional health status in midterm follow-up. Patients with repaired TOF who had previously completed CMR and assessment with the Short Form 36 version 2 (SF-36) were recruited for repeat CMR, SF-36, and exercise test, if they had not had interval pulmonary valve replacement (PVR). Patients from the same cohort who had undergone PVR were recruited for repeat SF-36. A total of 19 patients (median 33.5 years old, interquartile range [IQR] 26-42 years, 53 % male) had not undergone PVR and were enrolled at a median of 5.0 years (IQR 4.8-5.3) since prior CMR and SF-36. LVEF and RVEF did not change from baseline, while RV end-diastolic volume increased (138 ± 34 vs. 126 ± 31 ml/m(2), p = 0.02). In the overall cohort, SF-36 scores remained stable. However, higher baseline RV end-systolic volume and pulmonary regurgitant fraction correlated with subsequent decreases in SF-36 scores. In 9 patients post-PVR (median 35.9 years old, IQR 24-43), physical functioning increased compared to those without PVR (change in z-score +0.59 ± 0.59 vs. -0.26 ± 0.72, p = 0.005). In adults with repaired TOF who do not undergo PVR, LVEF, RVEF, and functional health status remain stable in midterm follow-up. However, baseline RV end-systolic volume correlates with subsequent change in functional health status, underscoring its importance in prognostication and timing of intervention in this population.

Relation of right ventricular mass and volume to functional health status in repaired tetralogy of Fallot

After repair of tetralogy of Fallot, right ventricular (RV) mass and mass:volume ratio may reflect RV remodeling and adverse outcomes. This study aimed to evaluate the relation of RV mass to functional health status and subsequent adverse RV remodeling and to determine whether RV mass measurement in systole could improve reproducibility. In 53 patients with tetralogy of Fallot (median 29 years old) who previously underwent cardiovascular magnetic resonance and completed the Short Form 36, version 2 (Optum, Eden Prairie, MN), short-axis images were analyzed for RV end-diastolic volume and diastolic and systolic mass, indexed to body surface area. The most recent subsequent cardiovascular magnetic resonance study (before pulmonary valve or conduit replacement) was evaluated for change in RV end-diastolic volume and ejection fraction. Diastolic indexed mass ≥37.3 g/m(2) (odds ratio 7.6, p = 0.02) predicted decreased general health scores. In patients with normal RV ejection fraction, indexed mass correlated with Physical Component Summary and general health scores. RV diastolic mass:volume ratio >0.2 had a strong association with subsequent increase in RV end-diastolic volume (odds ratio 26.1, p = 0.002). Systolic RV mass measurement had excellent correlation with diastolic measurement (r = 0.97, p <0.0001), but did not improve intraobserver or interobserver variability. In conclusion, RV mass relates to functional health status and adverse RV remodeling and can be measured with good reproducibility. RV mass should be routinely evaluated in this population and is best measured in diastole; further study is necessary to evaluate longitudinal changes in functional health status and RV parameters.

Unnatural history of tetralogy of Fallot: prospective follow-up of 40 years after surgical correction

BACKGROUND

Prospective data on long-term survival and clinical outcome beyond 30 years after surgical correction of tetralogy of Fallot are nonexistent.

METHODS AND RESULTS

This longitudinal cohort study consists of the 144 patients with tetralogy of Fallot who underwent surgical repair at <15 years of age between 1968 and 1980 in our center. They are investigated every 10 years. Cumulative survival (data available for 136 patients) was 72% after 40 years. Late mortality was due to heart failure and ventricular fibrillation. Seventy-two of 80 eligible survivors (90%) participated in the third in-hospital investigation, consisting of ECG, Holter, echocardiography, cardiopulmonary exercise testing, N-terminal pro-brain natriuretic peptide measurement, cardiac magnetic resonance (including dobutamine stress testing), and the Short Form-36 questionnaire. Median follow-up was 36 years (range, 31-43 years). Cumulative event-free survival was 25% after 40 years. Subjective health status was comparable to that in the normal Dutch population. Although systolic right and left ventricular function declined, peak exercise capacity remained stable. There was no progression of aortic root dilation. A previous shunt operation, low temperature during surgery, and early postoperative arrhythmias were found to predict late mortality (hazard ratio, 2.9, 1.1, and 2.5, respectively). An increase in QRS duration and a deterioration of exercise tolerance and ventricular dysfunction did not predict mortality. Insertion of a transannular patch was a predictor for late arrhythmias (hazard ratio, 4.0; 95% confidence interval, 1.2-13.4).

CONCLUSIONS

Although many patients needed a reoperation or developed arrhythmias, late mortality was low, and the clinical condition and subjective health status of most patients remained good. Previous shunt, low temperature during surgery, and early postoperative arrhythmias were found to predict late mortality.

2013 update on congenital heart disease, clinical cardiology, heart failure, and heart transplant

This article presents the most relevant developments in 2013 in 3 key areas of cardiology: congenital heart disease, clinical cardiology, and heart failure and transplant. Within the area of congenital heart disease, we reviewed contributions related to sudden death in adult congenital heart disease, the importance of specific echocardiographic parameters in assessing the systemic right ventricle, problems in patients with repaired tetralogy of Fallot and indication for pulmonary valve replacement, and confirmation of the role of specific factors in the selection of candidates for Fontan surgery. The most recent publications in clinical cardiology include a study by a European working group on correct diagnostic work-up in cardiomyopathies, studies on the cost-effectiveness of percutaneous aortic valve implantation, a consensus document on the management of type B aortic dissection, and guidelines on aortic valve and ascending aortic disease. The most noteworthy developments in heart failure and transplantation include new American guidelines on heart failure, therapeutic advances in acute heart failure (serelaxin), the management of comorbidities such as iron deficiency, risk assessment using new biomarkers, and advances in ventricular assist devices.

Surgical repair of pulmonary artery branches

Surgical repair of pulmonary artery (PA) branches encompasses many different clinical scenarios and technical challenges. The most common, such as bifurcation and central PA reconstruction, are described, as well as the challenges of complex and peripheral reconstruction.

Surgical management of tetralogy of fallot: in defense of the infundibulum

Surgical treatment of the Tetralogy of Fallot (ToF) is one of the great successes of medicine and also a topic of controversy. Different strategies have been proposed, including age-based (neonatal) management strategies as well as anatomic-based management strategies. Regardless of the management strategy entailed, the surgical management of ToF has considerably evolved over the years. As a result, patients can now expect excellent early results with survival approaching 100% for those without genetic syndromes. The goals of current surgical therapy should be to mitigate the late right ventricular (RV) dysfunction that may occur by minimizing the extent of surgical injury during the intial repair. As the surgical techniques continue to advance, the outcomes will continue to improve.

Usefulness of right ventricular free wall strain to predict quality of life in "repaired" tetralogy of Fallot

After repair of tetralogy of Fallot, the left ventricular ejection fraction and the right ventricular ejection fraction are associated with clinical status and outcomes, but the relation of strain, a potentially earlier marker of dysfunction, to quality of life has not been evaluated. In 58 patients with tetralogy of Fallot (median age 29 years, interquartile range 20 to 41) who underwent cardiovascular magnetic resonance imaging and completed the Short Form 36, Version 2 (a validated quality-of-life assessment), left ventricular global circumferential strain, left ventricular global longitudinal strain, and right ventricular free wall longitudinal strain (RVLSFW) were measured from cine images using feature-tracking software. Age-adjusted z score ≤-1 for the physical component summary or subscales of physical functioning, role-physical, and general health was considered a clinically significant decrease in quality of life. Patients with RVLSFW less than the median had increased odds of decreased physical functioning (odds ratio [OR] 5.4, p = 0.01) and general health (OR 3.5, p = 0.04) subscale scores, which remained significant in patients with right ventricular ejection fractions ≥45% (physical functioning: OR 9.5, p = 0.03; general health: OR 5.9, p = 0.04). Left ventricular global circumferential strain and left ventricular global longitudinal strain did not predict decreased quality of life in this population. Intraobserver and interobserver variability was acceptable for left ventricular global circumferential strain (coefficients of variation 9.5% and 10.0%, respectively) but lower for left ventricular global longitudinal strain (coefficients of variation 17.2% and 16.8%, respectively) and poor for RVLSFW (coefficients of variation 19.9% and 28.8%, respectively). In conclusion, RVLSFW appears to have discriminative ability in this population for decreased quality of life and may yield incremental prognostic value beyond global right ventricular ejection fraction assessment, but further study is needed to evaluate methods to limit variability.

Tetralogy of fallot: a surgical perspective

Tetralogy of Fallot (TOF) is an index lesion for all paediatric and congenital heart surgeons. In designing an appropriate operation for children with TOF, the predicted postoperative physiology must be taken into account, both for the short and long term. A favourable balance between pulmonary stenosis (PS) and pulmonary insufficiency (PI) may be critical for preservation of biventricular function. A unified repair strategy to limit both residual PS and PI is presented, along with supportive experimental evidence. A strategy for dealing with coronary anomalies and some comments regarding best timing of operation are also included.