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Leonardi B, Perrone M, Calcaterra G, Sabatino J, Leo I, Aversani M, Bassareo PP, Pozza A, Oreto L, Moscatelli S, Borrelli N, Bianco F, Di Salvo G. Repaired Tetralogy of Fallot: Have We Understood the Right Timing of PVR? J Clin Med 2024; 13:2682. [PMID: 38731211 PMCID: PMC11084704 DOI: 10.3390/jcm13092682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/23/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Despite many advances in surgical repair during the past few decades, the majority of tetralogy of Fallot patients continue to experience residual hemodynamic and electrophysiological abnormalities. The actual issue, which has yet to be solved, is understanding how this disease evolves in each individual patient and, as a result, who is truly at risk of sudden death, as well as the proper timing of pulmonary valve replacement (PVR). Our responsibility should be to select the most appropriate time for each patient, going above and beyond imaging criteria used up to now to make such a clinically crucial decision. Despite several studies on timing, indications, procedures, and outcomes of PVR, there is still much uncertainty about whether PVR reduces arrhythmia burden or improves survival in these patients and how to appropriately manage this population. This review summarizes the most recent research on the evolution of repaired tetralogy of Fallot (from adolescence onwards) and risk factor variables that may favor or delay PVR.
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Affiliation(s)
| | - Marco Perrone
- Clinical Pathways and Epidemiology Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
- Division of Cardiology and CardioLab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | | | - Jolanda Sabatino
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Isabella Leo
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (J.S.); (I.L.)
| | - Martina Aversani
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Pier Paolo Bassareo
- School of Medicine, University College of Dublin, Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland;
| | - Alice Pozza
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
| | - Lilia Oreto
- Dipartimento di Medicina Clinica e Sperimentale, Università di Messina, 98122 Messina, Italy;
| | - Sara Moscatelli
- Institute of Cardiovascular Sciences University College London, London WC1E 6BT, UK and Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK;
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO Dei Colli, Monaldi Hospital, 80131 Naples, Italy;
| | - Francesco Bianco
- Cardiovascular Sciences Department, AOU “Ospedali Riuniti”, 60126 Ancona, Italy;
| | - Giovanni Di Salvo
- Paediatric Cardiology and Congenital Heart Disease, University of Padua and Pediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy; (M.A.); (G.D.S.)
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Leonardi B, Cifra B. The Role of Cardiopulmonary Testing to Risk Stratify Tetralogy of Fallot Patients. CJC Pediatr Congenit Heart Dis 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cheng S, Li VWY, Cheung YF. Systolic and diastolic functional reserve of the subpulmonary and systemic right ventricles as assessed by pharmacologic and exercise stress: A systematic review. Echocardiography 2022; 39:310-329. [PMID: 34997638 DOI: 10.1111/echo.15285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 01/11/2023] Open
Abstract
We performed a systematic review of the literature on the assessment of subpulmonary and systemic right ventricular (RV) functional reserve during pharmacological and exercise stress in congenital heart patients and patients with pulmonary arterial hypertension (PAH). Literature search was conducted using PubMed, EMBASE, and MEDLINE from their inception up to August 2020. Of 913 records identified, 56 studies with a total of 1730 patients were included. Of the 56 studies, 23 assessed subpulmonary RV functional reserve in repaired tetralogy of Fallot patients, 19 assessed systemic RV reserve in patients with transposition of the great arteries (TGA) after atrial switch and those with congenitally corrected TGA, and 14 assessed subpulmonary RV research in patients with PAH. Pharmacological and exercise stress was used, respectively, in 22 and 34 studies. The main findings were (1) impairment of RV systolic and diastolic functional reserve, (2) associations between impaired functional reserve and worse baseline functional parameters, and (3) prognostic implications of RV systolic functional reserve on clinical outcomes in patients with volume and/or pressure-loaded subpulmonary and systemic right ventricles. Further studies are required to establish the incremental value of incorporating stress studies of RV systolic and diastolic function in the clinical management algorithm of congenital heart patients and patients with PAH.
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Affiliation(s)
- Sabine Cheng
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Vivian Wing-Yi Li
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
| | - Yiu-Fai Cheung
- Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, People's Republic of China
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Nayak KS, Lim Y, Campbell-Washburn AE, Steeden J. Real-Time Magnetic Resonance Imaging. J Magn Reson Imaging 2022; 55:81-99. [PMID: 33295674 PMCID: PMC8435094 DOI: 10.1002/jmri.27411] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 01/03/2023] Open
Abstract
Real-time magnetic resonance imaging (RT-MRI) allows for imaging dynamic processes as they occur, without relying on any repetition or synchronization. This is made possible by modern MRI technology such as fast-switching gradients and parallel imaging. It is compatible with many (but not all) MRI sequences, including spoiled gradient echo, balanced steady-state free precession, and single-shot rapid acquisition with relaxation enhancement. RT-MRI has earned an important role in both diagnostic imaging and image guidance of invasive procedures. Its unique diagnostic value is prominent in areas of the body that undergo substantial and often irregular motion, such as the heart, gastrointestinal system, upper airway vocal tract, and joints. Its value in interventional procedure guidance is prominent for procedures that require multiple forms of soft-tissue contrast, as well as flow information. In this review, we discuss the history of RT-MRI, fundamental tradeoffs, enabling technology, established applications, and current trends. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 1.
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Affiliation(s)
- Krishna S. Nayak
- Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, California, USA,Address reprint requests to: K.S.N., 3740 McClintock Ave, EEB 400C, Los Angeles, CA 90089-2564, USA.
| | - Yongwan Lim
- Ming Hsieh Department of Electrical and Computer Engineering, University of Southern California, Los Angeles, California, USA
| | - Adrienne E. Campbell-Washburn
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer Steeden
- Institute of Cardiovascular Science, Centre for Cardiovascular Imaging, University College London, London, UK
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Steinmetz M, Stümpfig T, Seehase M, Schuster A, Kowallick J, Müller M, Unterberg-Buchwald C, Kutty S, Lotz J, Uecker M, Paul T. Impaired Exercise Tolerance in Repaired Tetralogy of Fallot Is Associated With Impaired Biventricular Contractile Reserve: An Exercise-Stress Real-Time Cardiovascular Magnetic Resonance Study. Circ Cardiovasc Imaging 2021; 14:e011823. [PMID: 34384226 DOI: 10.1161/circimaging.120.011823] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Correction of tetralogy of Fallot (cTOF) often results in pulmonary valve pathology and right ventricular (RV) dysfunction. Reduced exercise capacity in cTOF patients cannot be explained by these findings alone. We aimed to explore why cTOF patients exhibit impaired exercise capacity with the aid of a comprehensive cardiopulmonary exercise testing (CPET) and real-time cardiovascular magnetic resonance exercise testing (CMR-ET) protocol. METHODS Thirty three cTOF patients and 35 matched healthy controls underwent CPET and CMR-ET in a prospective case-control study. Real-time steady-state free precession cine and phase-contrast sequences were obtained during incremental supine in-scanner cycling at 50, 70, and 90 W. RV and left ventricle (LV) volumes and pulmonary blood flow (Qp) were calculated. Differences of CPET and CMR-ET between cTOF versus controls and correlations between CPET and CMR-ET parameters in cTOF were evaluated statistically for all CMR exercise levels using Mann-Whitney U and Spearman rank-order correlation tests. RESULTS CPET capacity was significantly lower in cTOF than in controls. cTOF patients exhibited not only significantly reduced Qp and RV function but also lower LV function on CMR-ET. Higher CPET values in cTOF correlated with higher Qp (Qp 90 W versus carbon dioxide ventilatory equivalent %: R=-0.519, P<0.05), higher LV-end-diastolic volume indexed to body surface area (LV-end-diastolic volume indexed to body surface area at 50 W versus oxygen uptake in % at maximum exercise on CPET R=0.452, P<0.05), and change in LV ejection fraction (EF; LV-EF at 90 W versus Watt %: r=-0.463, P<0.05). No correlation was found with regard to RV-EF. Significant RV-LV interaction was observed during CMR-ET (RV-EF versus LV-EF at 50 W and 70 W: r=0.66, P<0.02 and r=0.52, P<0.05, respectively). CONCLUSIONS Impaired exercise capacity in cTOF resulted from a reduction in not only RV, but also LV function. cTOF with good exercise capacity on CPET demonstrated higher LV reserve and pulmonary blood flow during incremental CMR-ET. Apart from RV parameters, CMR-ET-derived LV function could be a valuable tool to stratify cTOF patients for pulmonary valve replacement.
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Affiliation(s)
- Michael Steinmetz
- Department of Pediatric Cardiology and Intensive Care Medicine (M. Steinmetz, T.S., M. Seehase, M.M., T.P.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Thomas Stümpfig
- Department of Pediatric Cardiology and Intensive Care Medicine (M. Steinmetz, T.S., M. Seehase, M.M., T.P.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Matthias Seehase
- Department of Pediatric Cardiology and Intensive Care Medicine (M. Steinmetz, T.S., M. Seehase, M.M., T.P.)
| | - Andreas Schuster
- Department of Cardiology and Pneumology (A.S., C.U.-B.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Johannes Kowallick
- Institute for Diagnostic and Interventional Radiology (J.K., C.U.-B., J.L., M.U.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Matthias Müller
- Department of Pediatric Cardiology and Intensive Care Medicine (M. Steinmetz, T.S., M. Seehase, M.M., T.P.)
| | - Christina Unterberg-Buchwald
- Department of Cardiology and Pneumology (A.S., C.U.-B.).,Institute for Diagnostic and Interventional Radiology (J.K., C.U.-B., J.L., M.U.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Shelby Kutty
- University Medical Center, Georg-August-University, Goettingen, Germany. The Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, MD (S.K.)
| | - Joachim Lotz
- Institute for Diagnostic and Interventional Radiology (J.K., C.U.-B., J.L., M.U.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
| | - Martin Uecker
- Institute for Diagnostic and Interventional Radiology (J.K., C.U.-B., J.L., M.U.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.).,Cluster of Excellence "Multiscale Bioimaging: From Molecular Machines to Networks of Excitable Cells" (MBExC), University of Goettingen, Germany (M.U.)
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine (M. Steinmetz, T.S., M. Seehase, M.M., T.P.).,DZHK, German Center for Cardiovascular Research (DZHK), partner site Goettingen (M. Steinmetz, T.S., A.S., J.K., C.U.-B., J.L., M.U., T.P.)
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Trankle CR, Canada JM, Jordan JH, Truong U, Hundley WG. Exercise Cardiovascular Magnetic Resonance: A Review. J Magn Reson Imaging 2021; 55:720-754. [PMID: 33655592 DOI: 10.1002/jmri.27580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
While pharmacologic stress cardiovascular magnetic resonance imaging (MRI) is a robust noninvasive tool in the diagnosis and prognostication of epicardial coronary artery disease, clinical guidelines recommend exercise-based testing in those patients who can exercise. This review describes the development of exercise cardiovascular MRI protocols, summarizes the insights across various patient populations, and highlights future research initiatives. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Cory R Trankle
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Justin M Canada
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer H Jordan
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Uyen Truong
- Division of Pediatric Cardiology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - W Gregory Hundley
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
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Rashid I, Mahmood A, Ismail TF, O’meagher S, Kutty S, Celermajer D, Puranik R. Right ventricular systolic dysfunction but not dilatation correlates with prognostically significant reductions in exercise capacity in repaired Tetralogy of Fallot. Eur Heart J Cardiovasc Imaging 2020; 21:906-13. [DOI: 10.1093/ehjci/jez245] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 07/28/2019] [Accepted: 09/11/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
The optimal timing for pulmonary valve replacement in asymptomatic patients with repaired Tetralogy of Fallot (rTOF) and pulmonary regurgitation remains uncertain but is often guided by increases in right ventricular (RV) end-diastolic volume. As cardiopulmonary exercise testing (CPET) performance is a strong prognostic indicator, we assessed which cardiovascular magnetic resonance (CMR) parameters correlate with reductions in exercise capacity to potentially improve identification of high-risk patients.
Methods and results
In all, 163 patients with rTOF (mean age 24.5 ± 10.2 years) who had previously undergone CMR and standardized CPET protocols were included. The indexed right and left ventricular end-diastolic volumes (RVEDVi, LVEDVi), right and left ventricular ejection fractions (RVEF, LVEF), indexed RV stroke volume (RVSVi), and pulmonary regurgitant fraction (PRF) were quantified by CMR and correlated with CPET-determined peak oxygen consumption (VO2) or peak work. On univariable analysis, there was no significant correlation between RVEDVi and PRF with peak VO2 or peak work (% Jones-predicted). In contrast, RVEF and RVSVi had significant correlations with both peak VO2 and peak work that remained significant on multivariable analysis. For a previously established prognostic peak VO2 threshold of <27 mL/kg/min, receiver-operating characteristic curve analysis demonstrated a Harrell’s c of 0.70 for RVEF (95% confidence interval 0.61–0.79) with a sensitivity of 88% for RVEF <40%.
Conclusion
In rTOF, CMR indices of RV systolic function are better predictors of CPET performance than RV size. An RVEF <40% may be useful to identify prognostically significant reductions in exercise capacity in patients with varying degrees of RV dilatation.
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Yamamura K, Sakamoto I, Morihana E, Hirata Y, Nagata H, Yamasaki Y, Okumura Y, Kohashi K, Koto K, Tsutsui H, Ohga S. Elevated non-invasive liver fibrosis markers and risk of liver carcinoma in adult patients after repair of tetralogy of Fallot. Int J Cardiol 2019; 287:121-6. [DOI: 10.1016/j.ijcard.2019.04.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 03/09/2019] [Accepted: 04/09/2019] [Indexed: 12/30/2022]
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Bhatt SM, Elci OU, Wang Y, Goldmuntz E, McBride M, Paridon S, Mercer-Rosa L. Determinants of Exercise Performance in Children and Adolescents with Repaired Tetralogy of Fallot Using Stress Echocardiography. Pediatr Cardiol 2019; 40:71-78. [PMID: 30121867 PMCID: PMC6349539 DOI: 10.1007/s00246-018-1962-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/11/2018] [Indexed: 01/07/2023]
Abstract
Exercise performance is variable and often impaired in patients with repaired tetralogy of Fallot (rTOF). We sought to identify factors associated with exercise performance by comparing high to low performers on cardiopulmonary exercise testing (CPET) in patients with rTOF. We conducted a cross-sectional study of subjects presenting for CPET who underwent echocardiograms at rest and peak exercise. Patients with pacemakers and arrhythmias were excluded. Right ventricular (RV) global longitudinal strain was used as a measure of systolic function. Pulmonary insufficiency (PI) was assessed with the diastolic systolic ratio and the diastolic systolic time-velocity integral ratio by Doppler interrogation of the pulmonary artery. CPET measures included percent-predicted maximum [Formula: see text][Formula: see text], percent-predicted maximum work and oxygen pulse. High versus low performers were identified as those achieving [Formula: see text] of at least 80% or falling below, respectively. Differences in echocardiographic parameters from rest to peak exercise were examined using mixed-effects regression models. Compared to the low performers (n = 17), high performers (n = 12) were younger (12.8 ± 3.3 years vs. 18.3 ± 4.8 years), had normal chronotropic response (peak heart rate > 185 bpm) with greater heart rate reserve and superior physical working capacity. High performers also had a greater reduction in PI at peak exercise, despite greater PI severity at rest. Oxygen pulse was comparable between groups. For both groups, there was no association of PI severity and RV systolic function at rest with exercise parameters. There was no group difference in the magnitude of change in RV strain and diastolic parameters from rest to peak exercise. Chronotropic response to exercise appears to be an important parameter with which to assess exercise performance in rTOF. Chronotropic health should be taken into consideration in this population, particularly given that RV function and PI severity at rest were not associated with exercise performance.
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Affiliation(s)
- Shivani M Bhatt
- Children's Hospital of Philadelphia, Philadelphia, PA, USA.
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Okan U Elci
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yan Wang
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Elizabeth Goldmuntz
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Michael McBride
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Stephen Paridon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Laura Mercer-Rosa
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Division of Cardiology, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Bhatt SM, Wang Y, Elci OU, Goldmuntz E, McBride M, Paridon S, Mercer-Rosa L. Right Ventricular Contractile Reserve Is Impaired in Children and Adolescents With Repaired Tetralogy of Fallot: An Exercise Strain Imaging Study. J Am Soc Echocardiogr 2018; 32:135-144. [PMID: 30269912 DOI: 10.1016/j.echo.2018.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pulmonary insufficiency (PI) and right ventricular (RV) dysfunction are long-term complications in patients with repaired tetralogy of Fallot (rTOF). The aim of this study was to investigate RV contractile reserve and changes in PI that occur during exercise in patients with rTOF and the associations of these changes with exercise performance using stress echocardiography. METHODS Subjects with rTOF (n = 32) and healthy control subjects (n = 10) were prospectively enrolled and underwent rest and peak exercise echocardiography during standard cardiopulmonary exercise test protocol on a cycle ergometer or treadmill. RV contractile reserve was defined as the change in RV global longitudinal strain from rest to peak exercise. PI was assessed with the diastolic-to-systolic time-velocity integral ratio and diastolic/systolic velocity ratio from pulmonary artery Doppler interrogation. Exercise measures included heart rate reserve, percentage predicted maximum oxygen consumption, percentage predicted maximum work, and oxygen pulse. RESULTS RV contractile reserve was impaired in patients with rTOF compared with control subjects, with a significant drop in the absolute value of RV global longitudinal strain from 17% (range, 8%-27%) at rest to 13% (range, 5%-28%) at peak exercise. Similarly, PI decreased at peak exercise, with decreases in diastolic-to-systolic time-velocity integral and diastolic/systolic velocity ratios. Reduction in PI was directly associated with percentage predicted maximum oxygen consumption, percentage predicted maximum work, and greater oxygen pulse. Heart rate reserve was directly associated with percentage predicted maximum oxygen consumption and percentage predicted maximum work. RV contractile reserve was not associated with any exercise parameters. CONCLUSIONS Patients with rTOF have an abnormal myocardial response to exercise with impaired RV contractile reserve compared with control subjects. Heart rate reserve and reduction in PI at peak exercise are associated with better exercise performance and appear to be significant contributors to exercise performance in rTOF. Measures to improve chronotropic health in rTOF should be explored.
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Affiliation(s)
- Shivani M Bhatt
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Yan Wang
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Okan U Elci
- Biostatistics and Data Management Core, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael McBride
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephen Paridon
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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DeFaria Yeh D, Stefanescu Schmidt AC, Eisman AS, Serfas JD, Naqvi M, Youniss MA, Ryfa AD, Khan AA, Safi L, Tabtabai SR, Bhatt AB, Lewis GD. Impaired right ventricular reserve predicts adverse cardiac outcomes in adults with congenital right heart disease. Heart 2018; 104:2044-2050. [DOI: 10.1136/heartjnl-2017-312572] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 05/25/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022] Open
Abstract
ObjectiveThe prevalence of heart failure (HF) among adult patients with congenital heart disease (ACHD) is rising. Right ventricle (RV) exercise reserve and its relationship to outcomes have not been characterised. We aim to evaluate the prognostic impact of impaired RV reserve in an ACHD population referred for cardiopulmonary exercise testing (CPET).MethodsThis retrospective study evaluates patients with ACHD who underwent CPET (n=147) with first-pass radionuclide ventriculography at a single tertiary care centre. RV reserve was categorised as normal, mild to moderately or severely impaired. The primary composite clinical outcome included clinical right HF, arrhythmia, transplantation or death.ResultsPatients were median age 41±13 years, 50% were female and median follow-up was 1.1 (IQR: 0.7–2.0) years. Exercise RV reserve was impaired in 103 patients (70%), of whom 32% were asymptomatic. Resting RV systolic function poorly predicted RV reserve, with 52% of patients with severe impairment having a qualitatively normal echocardiographic assessment. The severely impaired reserve group had lower peak oxygen consumption (VO2)(17.2 vs 22.5 mL/kg/min, p<0.0001) compared with the normal reserve group, and was more likely to develop the composite outcome (48% vs 9%, log-rank p<0.001). Severely impaired RV reserve predicted event-free survival after adjusting for peak VO2, age, sex, RV pathology, QRS duration, New York Heart Association class, resting RV ejection fraction and RV dilation by echocardiography or MRI (HR 3.7, 95% CI 1.1 to 13.0, p=0.039).ConclusionImpaired RV reserve, occurred in asymptomatic patients, was not well predicted by resting systolic function assessment, and strongly predicted adverse cardiovascular outcomes.
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Li J, Luo S, Liu F, An Q. Systolic Function of Right Ventricular Outflow Tract is a Better Predictor to Exercise Performance After Pulmonary Valve Replacement in Tetralogy of Fallot. Pediatr Cardiol 2017; 38:1556-61. [PMID: 28741094 DOI: 10.1007/s00246-017-1695-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/15/2017] [Indexed: 10/19/2022]
Abstract
Debate on the proper timing of pulmonary valve replacement (PVR) after repair of tetralogy of Fallot is still continuing. We aim to clarify how the different components of right ventricle (RV) changed with relieved volume overload in the remodeling process after pulmonary valve replacement and gain a clear idea of the relationship between different right ventricle components function and exercise capacity after PVR in these patients. The medical records and results of cardiac magnetic resonance imaging and cardiopulmonary exercise testing of 25 consecutive eligible patients were reviewed. End-diastolic, end-systolic, and ejection fraction (EF) were determined for the total RV and its components before and after PVR. There was a marked increase in EF for the outlet after PVR (39.5 ± 11.4 vs. 45.6 ± 12.7, P = 0.04); however, EF and volume change for the other components showed no significant difference. Peak oxygen consumption (VO2) correlated better with the RV outflow tract EF than with the EF of other components of the RV or the global EF (r = 0.382, P = 0.018), and the time interval between initial repair and PVR showed a significant correlation with peak VO2 (r = -0.339, P = 0.037). Multivariate analysis showed the RV outflow tract EF to be the only independent predictor of exercise capacity (β = 0.479; P = 0.046). The systolic function of the RV outflow tract could be a reliable determinant of intrinsic RV performance in repaired TOF (rTOF) patients and a promising parameter for deciding timing of pulmonary valve replacement so as to achieve the best possible exercise capacity in repaired TOF patients.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [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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Markl M, Schnell S, Wu C, Bollache E, Jarvis K, Barker AJ, Robinson JD, Rigsby CK. Advanced flow MRI: emerging techniques and applications. Clin Radiol. 2016;71:779-795. [PMID: 26944696 DOI: 10.1016/j.crad.2016.01.011] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 12/10/2015] [Accepted: 01/10/2016] [Indexed: 12/12/2022]
Abstract
Magnetic resonance imaging (MRI) techniques provide non-invasive and non-ionising methods for the highly accurate anatomical depiction of the heart and vessels throughout the cardiac cycle. In addition, the intrinsic sensitivity of MRI to motion offers the unique ability to acquire spatially registered blood flow simultaneously with the morphological data, within a single measurement. In clinical routine, flow MRI is typically accomplished using methods that resolve two spatial dimensions in individual planes and encode the time-resolved velocity in one principal direction, typically oriented perpendicular to the two-dimensional (2D) section. This review describes recently developed advanced MRI flow techniques, which allow for more comprehensive evaluation of blood flow characteristics, such as real-time flow imaging, 2D multiple-venc phase contrast MRI, four-dimensional (4D) flow MRI, quantification of complex haemodynamic properties, and highly accelerated flow imaging. Emerging techniques and novel applications are explored. In addition, applications of these new techniques for the improved evaluation of cardiovascular (aorta, pulmonary arteries, congenital heart disease, atrial fibrillation, coronary arteries) as well as cerebrovascular disease (intra-cranial arteries and veins) are presented.
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Padang R, Ganigara M, O'Meagher S, Grieve SM, Bannon PG, Celermajer DS, Jeremy R, Semsarian C, Puranik R. Feasibility of using real-time CMR imaging to evaluate acute thoracic aortic response to exercise. Int J Cardiol 2015; 197:306-8. [PMID: 26148771 DOI: 10.1016/j.ijcard.2015.05.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Ratnasari Padang
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Madhusudan Ganigara
- Sydney Medical School, University of Sydney, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Shamus O'Meagher
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia
| | - Stuart M Grieve
- Sydney Medical School, University of Sydney, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia; Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Paul G Bannon
- Sydney Medical School, University of Sydney, Sydney, Australia; The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, Australia; Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Richmond Jeremy
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, Sydney, Australia; Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rajesh Puranik
- Sydney Medical School, University of Sydney, Sydney, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; SMRI, RPAH Medical Centre, Sydney, Australia.
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