1
|
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.
Collapse
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.)
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Kim SJ, Li MH, Noh CI, Kim SH, Lee CH, Yoon JK. Impact of Pulmonary Arterial Elastance on Right Ventricular Mechanics and Exercise Capacity in Repaired Tetralogy of Fallot. Korean Circ J 2023; 53:406-417. [PMID: 37271746 DOI: 10.4070/kcj.2022.0228] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/25/2023] [Accepted: 03/01/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pathophysiological changes of right ventricle (RV) after repair of tetralogy of Fallot (TOF) are coupled with a highly compliant low-pressure pulmonary artery (PA) system. This study aimed to determine whether pulmonary vascular function was associated with RV parameters and exercise capacity, and its impact on RV remodeling after pulmonary valve replacement. METHODS In a total of 48 patients over 18 years of age with repaired TOF, pulmonary arterial elastance (Ea), RV volume data, and RV-PA coupling ratio were calculated and analyzed in relation to exercise capacity. RESULTS Patients with a low Ea showed a more severe pulmonary regurgitation volume index, greater RV end-diastolic volume index, and greater effective RV stroke volume (p=0.039, p=0.013, and p=0.011, respectively). Patients with a high Ea had lower exercise capacity than those with a low Ea (peak oxygen consumption [peak VO2] rate: 25.8±7.7 vs. 34.3±5.5 mL/kg/min, respectively, p=0.003), while peak VO2 was inversely correlated with Ea and mean PA pressure (p=0.004 and p=0.004, respectively). In the univariate analysis, a higher preoperative RV end-diastolic volume index and RV end-systolic volume index, left ventricular end-systolic volume index, and higher RV-PA coupling ratio were risk factors for suboptimal outcomes. Preoperative RV volume and RV-PA coupling ratio reflecting the adaptive PA system response are important factors in optimal postoperative results. CONCLUSIONS We found that PA vascular dysfunction, presenting as elevated Ea in TOF, may contribute to exercise intolerance. However, Ea was inversely correlated with pulmonary regurgitation (PR) severity, which may prevent PR, RV dilatation, and left ventricular dilatation in the absence of significant pulmonary stenosis.
Collapse
Affiliation(s)
- Soo-Jin Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Mei Hua Li
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
- The Sixth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chung Il Noh
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea.
| | - Seong-Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Ja-Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| |
Collapse
|
4
|
Leonardi B, Gentili F, Perrone MA, Sollazzo F, Cocomello L, Silva Kikina S, Wald RM, Palmieri V, Secinaro A, Gagliardi MG, Parisi A, Turchetta A, Galletti L, Bianco M, Drago F. Cardiopulmonary Exercise Testing in Repaired Tetralogy of Fallot: Multiparametric Overview and Correlation with Cardiac Magnetic Resonance and Physical Activity Level. J Cardiovasc Dev Dis 2022; 9:26. [PMID: 35050237 PMCID: PMC8778451 DOI: 10.3390/jcdd9010026] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/07/2022] [Accepted: 01/10/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with repaired Tetralogy of Fallot (rToF) typically report having preserved subjective exercise tolerance. Chronic pulmonary regurgitation (PR) with varying degrees of right ventricular (RV) dilation as assessed by cardiac magnetic resonance imaging (MRI) is prevalent in rToF and may contribute to clinical compromise. Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity, and the International Physical Activity Questionnaire (IPAQ) can provide additional data on physical activity (PA) achieved. Our aim was to assess the association between CPET values, IPAQ measures, and MRI parameters. All rToF patients who had both an MRI and CPET performed within one year between March 2019 and June 2021 were selected. Clinical data were extracted from electronic records (including demographic, surgical history, New York Heart Association (NYHA) functional class, QRS duration, arrhythmia, MRI parameters, and CPET data). PA level, based on the IPAQ, was assessed at the time of CPET. Eighty-four patients (22.8 ± 8.4 years) showed a reduction in exercise capacity (median peak VO2 30 mL/kg/min (range 25–33); median percent predicted peak VO2 68% (range 61–78)). Peak VO2, correlated with biventricular stroke volumes (RVSV: β = 6.11 (95%CI, 2.38 to 9.85), p = 0.002; LVSV: β = 15.69 (95% CI 10.16 to 21.21), p < 0.0001) and LVEDVi (β = 8.74 (95%CI, 0.66 to 16.83), p = 0.04) on multivariate analysis adjusted for age, gender, and PA level. Other parameters which correlated with stroke volumes included oxygen uptake efficiency slope (OUES) (RVSV: β = 6.88 (95%CI, 1.93 to 11.84), p = 0.008; LVSV: β = 17.86 (95% CI 10.31 to 25.42), p < 0.0001) and peak O2 pulse (RVSV: β = 0.03 (95%CI, 0.01 to 0.05), p = 0.007; LVSV: β = 0.08 (95% CI 0.05 to 0.11), p < 0.0001). On multivariate analysis adjusted for age and gender, PA level correlated significantly with peak VO2/kg (β = 0.02, 95% CI 0.003 to 0.04; p = 0.019). We observed a reduction in objective exercise tolerance in rToF patients. Biventricular stroke volumes and LVEDVi were associated with peak VO2 irrespective of RV size. OUES and peak O2 pulse were also associated with biventricular stroke volumes. While PA level was associated with peak VO2, the incremental value of this parameter should be the focus of future studies.
Collapse
|
5
|
Masood IR, Detterich J, Cerrone D, Lewinter K, Shah P, Kato R, Sabati A. Reduced Forced Vital Capacity and the Number of Chest Wall Surgeries are Associated with Decreased Exercise Capacity in Children with Congenital Heart Disease. Pediatr Cardiol 2022; 43:54-61. [PMID: 34365518 DOI: 10.1007/s00246-021-02692-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 03/03/2021] [Accepted: 07/23/2021] [Indexed: 10/20/2022]
Abstract
Low forced vital capacity (FVC) is associated with decreased exercise capacity in CHD. Multiple prior cardiac surgeries have been associated with low FVC. We seek to understand the relationship between low FVC, number of cardiac surgeries and cardiopulmonary response leading to decreased exercise capacity. Retrospective chart review of demographics, surgical history and exercise testing including spirometry was performed in patients with CHD. Single ventricle patients were excluded. Low FVC was defined as a Z-score below the lower limit of normal. Exercise parameters were expressed as a percent of predicted. There were 93 patients with 2 ventricle CHD identified over 34 months with cardiopulmonary exercise testing. The FVC Z-score directly correlated with peak V̇O2% (R2 = 0.07, p < 0.05), and the O2 pulse% (R2 = 0.25, p < 0.0001). The VE/VCO2 was inversely related to the FVC Z-score (R2 = 0.11, p < 0.01). Patients with minimum three prior surgeries had decreased peak VO2% (63.7 vs. 72.8, p < 0.05), decreased peak O2 pulse% (80.8 vs. 97.9, p < 0.01) and a lower mean FVC Z-score (- 1.9 vs - 0.38, p < 0.01). The FVC Z-score and number of surgeries both predicted peak V̇O2% in multivariate analysis. Our study demonstrated that low FVC and three or more prior cardiac surgeries were associated with lower exercise capacity and lower stroke volume response. More cardiac surgeries were also associated with low FVC. However, both low FVC and the number of surgeries were independent predictors of exercise capacity.
Collapse
Affiliation(s)
- Imran R Masood
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA.
| | - Jon Detterich
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Daniel Cerrone
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Katherine Lewinter
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Payal Shah
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Roberta Kato
- Children's Hospital of Los Angeles, 4650 Sunset Blvd., Los Angeles, CA, 90027, USA
| | | |
Collapse
|
6
|
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.
Collapse
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.)
| |
Collapse
|
7
|
Van den Eynde J, Sá MPBO, Vervoort D, Roever L, Meyns B, Budts W, Gewillig M, Ruhparwar A, Zhigalov K, Weymann A. Pulmonary Valve Replacement in Tetralogy of Fallot: An Updated Meta-Analysis. Ann Thorac Surg 2020; 113:1036-1046. [PMID: 33378694 DOI: 10.1016/j.athoracsur.2020.11.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND The benefits of pulmonary valve replacement (PVR) for pulmonary insufficiency in patients with repaired tetralogy of Fallot are still incompletely understood, and optimal timing remains challenging. METHODS We systematically reviewed databases (PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials /Cochrane Controlled Trials Register, ClinicalTrials.gov, Scientific Electronic Library Online, Literatura Latino Americana em Ciências da Saúde, and Google Scholar) and reference lists of relevant articles for studies about PVR in repaired tetralogy of Fallot patients that reported any of the following outcomes: mortality and redo PVR rates, right ventricular (RV) and left ventricular measures, QRS duration, cardiopulmonary exercise test results, or brain natriuretic peptide. In addition to calculating the pooled treatment effects using a random-effects meta-analysis, we evaluated the effect of preoperative measures on PVR outcomes using meta-regressions. RESULTS Eighty-four studies involving 7544 patients met the eligibility criteria. Pooled mortality at 30 days, 5 years, and 10 years after PVR was 0.87% (63 of 7253 patients, 80 studies), 2.7% (132 of 4952 patients, 37 studies), and 6.2% (510 of 2765 patients, 15 studies), respectively. Pooled 5- and 10-year redo PVR rates were 3.7% (141 of 3755 patients, 23 studies) and 16.8% (172 of 3035 patients, 16 studies), respectively. The results of the previous meta-analysis could be confirmed. In addition, we demonstrated that after PVR (1) QRS duration, cardiopulmonary exercise test results, and RV and left ventricular measures longitudinal strain do not significantly change; (2) brain natriuretic peptide decreases; and (3) greater indexed RV end-diastolic and end-systolic volumes are associated with lower chances of RV volume normalization after PVR. CONCLUSIONS This updated meta-analysis provides evidence about the benefits of PVR.
Collapse
Affiliation(s)
- Jef Van den Eynde
- Unit of Cardiac Surgery, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
| | - Michel Pompeu B O Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, University of Pernambuco, Recife, Pernambuco, Brazil
| | | | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Minas Gerais, Uberlândia, Brazil
| | - Bart Meyns
- Unit of Cardiac Surgery, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital and Structural Cardiology University Hospitals Leuven and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Marc Gewillig
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| |
Collapse
|
8
|
Avesani M, Borrelli N, Krupickova S, Sabatino J, Donne GD, Ibrahim A, Piccinelli E, Josen M, Michielon G, Fraisse A, Iliceto S, Di Salvo G. Echocardiography and cardiac magnetic resonance in children with repaired tetralogy of Fallot: New insights in cardiac mechanics and exercise capacity. Int J Cardiol 2020; 321:144-9. [PMID: 32702408 DOI: 10.1016/j.ijcard.2020.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 03/09/2020] [Revised: 05/24/2020] [Accepted: 07/15/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pulmonary regurgitation (PR) and right ventricular (RV) dilatation and disfunction are common in patients with repaired Tetralogy of Fallot (r-TOF). AIMS To compare Echo data with the gold standard CMR in a paediatric population of r-TOF with significant PR, to assess the reliability of standard and advanced echo parameters. In addition, to evaluate their correlation with peak oxygen consumption (VO2). METHODS AND RESULTS All patients underwent standard echo-Doppler study, speckle tracking analysis, and CMR to assess PR and RV size and function. Thirty-six patients underwent also cardiopulmonary exercise test. Fourty-six patients (aged 13.7 ± 3.0) were included. Echo derived RV areas correlated with CMR RV volumes (p < .0001, r = 0.72). RV end-diastolic area > 21.9 cm2/m2 had a good sensitivity (83.3%) and specificity (73.5%) to identify a RV end-diastolic volume ≥ 150 ml/m2. RVEF was preserved in all patients, while TAPSE was reduced in 78.2% and RVGLS in 60.8%. Flow-reversal in pulmonary branches showed a sensitivity of 95.8% and a specificity of 59.1% to identify CMR pulmonary regurgitant fraction (RF) ≥ 35%. None of the CMR parameters correlated with peak VO2. Among the Echo data only right atrial strain (RAS) correlated with peak VO2. CONCLUSION: In children, flow-reversal in pulmonary branches identifies hemodynamically significant RF with a good sensitivity but poor specificity. RV area by echocardiogram is a valid first-line parameter to screen RV dilation. RV longitudinal systolic dysfunction coexists with a still preserved EF. RAS correlates strongly with peak VO2 and should be added in their follow up.
Collapse
|
9
|
Alborikan S, Pandya B, Von Klemperer K, Walker F, Cullen S, Badiani S, Bhattacharyya S, Lloyd G. Cardiopulmonary Exercise Test (CPET) in patients with repaired Tetralogy of Fallot (rTOF); A systematic review. International Journal of Cardiology Congenital Heart Disease 2020; 1:100050. [DOI: 10.1016/j.ijcchd.2020.100050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
10
|
Guirgis L, Khraiche D, Ladouceur M, Iserin L, Bonnet D, Legendre A. Cardiac performance assessment during cardiopulmonary exercise test can improve the management of children with repaired congenital heart disease. Int J Cardiol 2020; 300:121-126. [DOI: 10.1016/j.ijcard.2019.10.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/03/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
|
11
|
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.
Collapse
|
12
|
Abstract
Tetralogy of Fallot (ToF) is the most common type of cyanotic congenital heart disease. Since the first surgical repair in 1954, treatment has continuously improved. The treatment strategies currently used in the treatment of ToF result in excellent long-term survival (30 year survival ranges from 68.5% to 90.5%). However, residual problems such as right ventricular outflow tract obstruction, pulmonary regurgitation, and (ventricular) arrhythmia are common and often require re-interventions. Right ventricular dysfunction can be seen following longstanding pulmonary regurgitation and/or stenosis. Performing pulmonary valve replacement or relief of pulmonary stenosis before irreversible right ventricular dysfunction occurs is important, but determining the optimal timing of pulmonary valve replacement is challenging for several reasons. The biological mechanisms underlying dysfunction of the right ventricle as seen in longstanding pulmonary regurgitation are poorly understood. Different methods of assessing the right ventricle are used to predict impending dysfunction. The atrioventricular, ventriculo-arterial and interventricular interactions of the right ventricle play an important role in right ventricle performance, but are not fully elucidated. In this review we present a brief overview of the history of ToF, describe the treatment strategies currently used, and outline the long-term survival, residual lesions, and re-interventions following repair. We discuss important remaining challenges and present the current state of the art regarding these challenges.
Collapse
Affiliation(s)
- Jelle P.G. van der Ven
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Eva van den Bosch
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Ad J.C.C. Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Cardiology, Radboud UMC - Amalia Children's Hospital, Nijmegen, The Netherlands
| |
Collapse
|
13
|
Gnanappa GK, Celermajer DS, Zhu D, Puranik R, Ayer J. Severe right ventricular dilatation after repair of Tetralogy of Fallot is associated with increased left ventricular preload and stroke volume. Eur Heart J Cardiovasc Imaging 2019; 20:1020-1026. [DOI: 10.1093/ehjci/jez035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/11/2018] [Accepted: 02/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
Pulmonary regurgitation (PR) and right ventricular (RV) dilatation are common in repaired tetralogy of Fallot (rTOF). Left ventricular (LV) dysfunction is an important risk factor in rTOF. The effect of PR/RV dilatation on LV performance and RV-LV interactions in rTOF are incompletely understood. We examined LV responses and exercise capacity in rTOF, both before and after pulmonary valve replacement (PVR).
Methods and results
Cardiac magnetic resonance imaging scans in 126 rTOF patients (age 17.3 ± 7.6 years) were analysed, comparing subjects with indexed RV end-diastolic volume (RVEDVi) <170 mL/m2 (mild/moderate dilatation, n = 95) and RVEDVi ≥170 mL/m2 (severe dilatation, n = 31). Indexed PR volume (PRVi), RV end-systolic (RVESVi), RV end-diastolic (RVEDVi), RV stroke volume (RVSVi), net pulmonary forward flow (NPFFi), LV end-diastolic (LVEDVi), LV end-systolic (LVESVi), LV stroke volume (LVSVi), RV and LV ejection fraction (EF), and diastolic septal curvature were obtained. Peak aerobic capacity (VO2 max) was measured. In a subset (n = 30), measures were obtained pre-and-post surgical PVR. Compared to those with mild/moderate RV dilatation, patients with severe RV dilation had greater PRVi (38 ± 12 vs. 24 ± 9 mL/m2, P < 0.0001), NPFFi (53 ± 9 vs. 44 ± 11 mL/m2, P < 0.0001), LVEDVi (87 ± 14 vs. 73 ± 13 mL/m2, P < 0.0001), LVESVi (39 ± 12 vs. 30 ± 8 mL/m2, P < 0.0001), and LVSVi (48 ± 7 vs. 43 ± 8 mL/m2, P = 0.002) but lower RV ejection fraction (46 ± 8 vs. 53 ± 7%, P < 0.0001). Septal curvature and VO2 max were similar in both groups. After PVR, there was no change in LVEDVi, LVSVi, septal curvature, or VO2 max.
Conclusions
Chronic PR with severe RV dilatation is associated with increased NPFFi, LVEDVi, and LVSVi. This may potentially explain preserved exercise capacity in rTOF with severe PR and RV dilatation.
Collapse
Affiliation(s)
- Ganesh Kumar Gnanappa
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
| | - David S Celermajer
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Danyi Zhu
- School of Electrical and Information Technology, University of Sydney, Maze Crescent, Darlington, New South Wales 2006, Australia
| | - Rajesh Puranik
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Department of Cardiology, The Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children’s Hospital at Westmead, Corner of Hawkesbury Road and Hainsworth Street, Westmead, New South Wales 2145, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Guccione P, Iorio FS, Rebonato M, Bennati E, Spaziani G, Amodeo A, Perri G, Parisi F, Favilli S. Profiles of heart failure in adolescents and young adults with congenital heart disease. Progress in Pediatric Cardiology 2018; 51:37-45. [DOI: 10.1016/j.ppedcard.2018.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
16
|
Dłużniewska N, Podolec P, Skubera M, Smaś-Suska M, Pająk J, Urbańczyk-Zawadzka M, Płazak W, Olszowska M, Tomkiewicz-Pająk L. Long-term follow-up in adults after tetralogy of Fallot repair. Cardiovasc Ultrasound 2018; 16:28. [PMID: 30373624 PMCID: PMC6206664 DOI: 10.1186/s12947-018-0146-7] [Citation(s) in RCA: 14] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 10/08/2018] [Indexed: 11/29/2022] Open
Abstract
Background Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease and the population of ToF repair survivors is growing rapidly. Adults with repaired ToF develop late complications. The aim of this study was to describe and analyze long-term follow-up of patients with repaired ToF. Methods This is a retrospective cohort study. Consecutive 83 patients with repaired ToF who did not undergo pulmonary valve replacement were included. Mean age of all patients was 30.5 ± 10.7. There were 49 (59%) male. Patients were divided into two groups according to the time since the repair (< 25 years and ≥ 25 years). The electrocardiographic (ECG), cardiopulmonary exercise testing (CPET), echocardiographic and cardiac magnetic resonance (CMR) data were reviewed retrospectively. Results In CPET values were not significantly different in the two groups. In CMR volumes of left and right ventricles were not significantly different in the two groups. There were no differences between the groups in ventricular ejection fraction, mass of ventricles, or pulmonary regurgitation fraction. Among all the patients, ejection fraction and left and right ventricle mass, indexed pulmonary regurgitation volume measured by CMR did not correlate with the time since repair. In ECG among all the patients, ejection fraction of the RV, measured in CMR, negatively correlated with QRS duration (r = − 0.43; p < 0.001). There was a positive correlation between QRS duration and end diastolic volume of the RV (r = 0.30; p < 0.02), indexed end diastolic volume of the RV (r = 0.29; p = 0.04), RV mass (r = 0.36; p < 0.001) and left ventricle mass (r = 0.26; p = 0.04). Conclusion Long-term survival and clinical condition after surgical correction of ToF in infancy is generally good and the late functional status in ToF – operated patients could be excellent up to 25 years after the repair. QRS duration could be an utility and easy factor to assessment of right ventricular function. Trial registration The study protocol was approved by the local Ethics Committee. Each participant provided informed consent to participate in the study (license number 122.6120.88.2016 from 28.04.2016).
Collapse
Affiliation(s)
- Natalia Dłużniewska
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Maciej Skubera
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Monika Smaś-Suska
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Jacek Pająk
- Paediatric Heart Surgery Department and General Paediatric Surgery Department, Medical University of Warsaw, Warsaw, Poland
| | | | - Wojciech Płazak
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Maria Olszowska
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Disease, Collegium Medicum, Jagiellonian University, John Paul II Hospital, Krakow, Poland.
| |
Collapse
|
17
|
Louis C, Swartz MF, Simon BV, Cholette JM, Atallah-Yunes N, Wang H, Gensini F, Alfieris GM. Modified Repair of Type I and II Truncus Arteriosus Limits Early Right Ventricular Outflow Tract Reoperation. Semin Thorac Cardiovasc Surg 2018; 30:199-204. [DOI: 10.1053/j.semtcvs.2018.02.003] [Citation(s) in RCA: 4] [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] [Accepted: 02/01/2018] [Indexed: 11/11/2022]
|
18
|
Abstract
Tetralogy of Fallot is the most common form of cyanotic congenital heart disease. As a result of the surgical strategies employed at the time of initial repair, chronic pulmonary regurgitation (PR) is prevalent in this population. Despite sustained research efforts, patient selection and timing of pulmonary valve replacement (PVR) to address PR in young asymptomatic patients with repaired tetralogy of Fallot (rToF) remain a fundamental but as yet unanswered question in the field of congenital heart disease. The ability of the heart to compensate for the chronic volume overload imposed by PR is critical in the evaluation of the risks and benefits of PVR. The difficulty in clarifying the functional impact of PR on the cardiovascular capacity may be in part responsible for the uncertainty surrounding the timing of PVR. Cardiopulmonary exercise testing (CPET) may be used to assess abnormal cardiovascular response to increased physiologic demands. However, its use as a tool for risk stratification in asymptomatic adolescents and young adults with rToF is still ill-defined. In this paper, we review the role of CPET as a potentially valuable adjunct to current risk stratification strategies with a focus on asymptomatic rToF adolescents and young adults being considered for PVR. The role of maximal and submaximal exercise measurements to identify young patients with a decreased or borderline low peak VO2 resulting from impaired ventricular function is explored. Current knowledge gaps and research perspectives are highlighted.
Collapse
|
19
|
Dennis M, Moore B, Kotchetkova I, Pressley L, Cordina R, Celermajer DS. Adults with repaired tetralogy: low mortality but high morbidity up to middle age. Open Heart 2017; 4:e000564. [PMID: 28698799 PMCID: PMC5495176 DOI: 10.1136/openhrt-2016-000564] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/22/2016] [Indexed: 12/23/2022] Open
Abstract
Objective Survival of patients with repaired tetralogy of Fallot (rToF) into young adulthood is very good. Concerns exist, however, over long-term morbidity and mortality as these subjects reach middle age. We aimed to assess survival and the prevalence of complications in patients with rToF seen in our Adult Congenital Heart Disease (ACHD) service. Methods One hundred and sixty-eight consecutive patients with ‘simple rToF’, aged over 16 years, followed up at our tertiary-level ACHD service in Sydney, Australia since 2000, were included. We documented mortality and analysed the prospectively defined composite end points of (a) ‘Serious adverse events’, including death, heart failure hospitalisation and/or documented ventricular arrhythmia and (b) ‘Adverse events’ inclusive of the above and endocarditis, atrial arrhythmia, defibrillator and/or pacemaker implantation. Results Mean age at the last follow-up was 34±12 years, and 55% were men. There were 10 (6%) deaths, and 26 patients (16%) experienced a ‘serious adverse event’. Fifty-one patients (30%) experienced an ‘adverse event’ and 29 patients had atrial arrhythmias. One hundred and one (61%) patients had at least one pulmonary valve replacement. By age 40 years, 93% were free of serious adverse events, and 83% were free of any adverse event. By age 50 years, only 56% had not had an adverse event. Older age and history of atrial arrhythmia were predictive of serious adverse events. Conclusion Survival into mid-adulthood in patients with rToF is very good; however, a substantial number of survivors have adverse events by the age of 50 years.
Collapse
Affiliation(s)
- Mark Dennis
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Ben Moore
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Irina Kotchetkova
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Lynne Pressley
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Rachael Cordina
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| |
Collapse
|
20
|
Simon BV, Swartz MF, Egan M, Cholette JM, Gensini F, Alfieris GM. Use of a Dacron Annular Sparing Versus Limited Transannular Patch With Nominal Pulmonary Annular Expansion in Infants With Tetralogy of Fallot. Ann Thorac Surg 2017; 103:186-192. [DOI: 10.1016/j.athoracsur.2016.05.056] [Citation(s) in RCA: 14] [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: 01/26/2016] [Revised: 04/15/2016] [Accepted: 05/11/2016] [Indexed: 11/27/2022]
|
21
|
Legendre A, Richard R, Pontnau F, Jais JP, Dufour M, Grenier O, Mousseaux E, Ladouceur M, Iserin L, Bonnet D. Usefulness of maximal oxygen pulse in timing of pulmonary valve replacement in patients with isolated pulmonary regurgitation. Cardiol Young 2016; 26:1310-8. [PMID: 26692200 DOI: 10.1017/S1047951115002504] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Patients with pulmonary regurgitation after tetralogy of Fallot repair have impaired aerobic capacity; one of the reasons is the decreasing global ventricular performance at exercise, reflected by decreasing peak oxygen pulse. The aims of our study were to evaluate the impact of pulmonary valve replacement on peak oxygen pulse in a population with pure pulmonary regurgitation and with different degrees of right ventricular dilatation and to determine the predictors of peak oxygen pulse after pulmonary valve replacement. The mean and median age at pulmonary valve replacement was 27 years. Mean pre-procedural right ventricular end-diastolic volume was 182 ml/m2. Out of 24 patients, 15 had abnormal peak oxygen pulse before pulmonary valve replacement. We did not observe a significant increase in peak oxygen pulse after pulmonary valve replacement (p=0.76). Among cardiopulmonary test/MRI/historical pre-procedural parameters, peak oxygen pulse appeared to be the best predictor of peak oxygen pulse after pulmonary valve replacement (positive and negative predictive values, respectively, 0.94 and 1). After pulmonary valve replacement, peak oxygen pulse was well correlated with left ventricular stroke and end-diastolic volumes (r=0.67 and 0.68, respectively). Our study confirms the absence of an effect of pulmonary valve replacement on peak oxygen pulse whatever the initial right ventricular volume, reflecting possible irreversible right and/or left ventricle lesions. Pre-procedural peak oxygen pulse seemed to well predict post-procedural peak oxygen pulse. These results encourage discussions on pulmonary valve replacement in patients showing any decrease in peak oxygen pulse during their follow-up.
Collapse
|
22
|
House AV, Danford DA, Spicer RL, Kutty S. Impact of clinical follow-up and diagnostic testing on intervention for tetralogy of Fallot. Open Heart 2015; 2:e000185. [PMID: 25973212 PMCID: PMC4422920 DOI: 10.1136/openhrt-2014-000185] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 02/03/2015] [Accepted: 03/04/2015] [Indexed: 12/01/2022] Open
Abstract
Objective Our purpose was to evaluate yield of tools commonly advocated for surveillance of tetralogy of Fallot (TOF). Methods All patients (pts) with TOF, seen at any time from 1/2008 to 9/2013 in an academic cardiology practice were studied. At the first and each subsequent outpatient visit, the use of tools including history and physical (H&P), ECG, Holter (HOL), echocardiogram (Echo), MR or CT (MR-CT) and stress testing (STR) were noted. Recommendations for intervention (INT) and for time to next follow-up were recorded; rationale for each INT with attribution to one or more tools was identified. Results There were 213 pts (mean 11.5 years, 130 male) who had 916 visits, 123 of which (13.4%) were associated with 138 INTs (47 surgical, 54 catheter-mediated, 37 other medical). Recommended follow-up interval was 9.44±6.5 months, actual mean follow-up interval was 11.7 months. All 916 (100%) patient visits had a H&P which contributed to 47.2% of INT decisions. Echo was performed in 652 (71.2%) of visits, and contributed to 53.7% of INTs. MR-CT was obtained in 129 (14.1%) of visits, and contributed to 30.1% of INTs. ECG was applied in 137 (15%) visits, and contributed to 1.6% of INTs. HOL was obtained in 188 (20.5%) visits, and contributed to 11.3% of INTs. STR was performed at 101 (11%) of visits, and contributed to 8.9% of INTs. Conclusions INTs are common in repaired TOF, but when visits average every 11–12 months, most visits do not result in INT. H&P, Echo and HOL were the most frequently applied screens, and all frequently yielded relevant information to guide INT decisions. STR and MR/CT were applied as targeted testing and in this limited, non-screening role had high relevance for INT. There was low utilisation of ECG and major impact on INT was not demonstrated. Risk stratification in TOF may be possible, and could result in more efficient surveillance and targeted testing.
Collapse
Affiliation(s)
- Aswathy Vaikom House
- Division of Pediatric Cardiology , University of Nebraska College of Medicine and Children's Hospital and Medical Center , Omaha, Nebraska , USA
| | - David A Danford
- Division of Pediatric Cardiology , University of Nebraska College of Medicine and Children's Hospital and Medical Center , Omaha, Nebraska , USA
| | - Robert L Spicer
- Division of Pediatric Cardiology , University of Nebraska College of Medicine and Children's Hospital and Medical Center , Omaha, Nebraska , USA
| | - Shelby Kutty
- Division of Pediatric Cardiology , University of Nebraska College of Medicine and Children's Hospital and Medical Center , Omaha, Nebraska , USA
| |
Collapse
|
23
|
Mercer-Rosa L, Paridon SM, Fogel MA, Rychik J, Tanel RE, Zhao H, Zhang X, Yang W, Shults J, Goldmuntz E. 22q11.2 deletion status and disease burden in children and adolescents with tetralogy of Fallot. ACTA ACUST UNITED AC 2015; 8:74-81. [PMID: 25561045 DOI: 10.1161/circgenetics.114.000819] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patients with repaired tetralogy of Fallot experience variable outcomes for reasons that are incompletely understood. We hypothesize that genetic variants contribute to this variability. We sought to investigate the association of 22q11.2 deletion status with clinical outcome in patients with repaired tetralogy of Fallot. METHODS AND RESULTS We performed a cross-sectional study of tetralogy of Fallot subjects who were tested for 22q11.2 deletion, and underwent cardiac magnetic resonance, exercise stress test, and review of medical history. We studied 165 subjects (12.3±3.1 years), of which 30 (18%) had 22q11.2 deletion syndrome (22q11.2DS). Overall, by cardiac magnetic resonance the right ventricular ejection fraction was 60±8%, pulmonary regurgitant fraction was 34±17%, and right ventricular end-diastolic volume was 114±39 cc/m(2). On exercise stress test, maximum oxygen consumption was 76±16% predicted. Despite comparable right ventricular function and pulmonary regurgitant fraction, on exercise stress test the 22q11.2DS had significantly lower percent predicted: forced vital capacity (61.5±16 versus 80.5±14; P<0.0001), maximum oxygen consumption (61±17 versus 80±12; P<0.0001), and work (64±18 versus 86±22, P=0.0002). Similarly, the 22q11.2DS experienced more hospitalizations (6.5 [5-10] versus 3 [2-5]; P<0.0001), saw more specialists (3.5 [2-9] versus 0 [0-12]; P<0.0001), and used ≥1 medications (67% versus 34%; P<0.001). CONCLUSIONS 22q11.2DS is associated with restrictive lung disease, worse aerobic capacity, and increased morbidity, and may explain some of the clinical variability seen in tetralogy of Fallot. These findings may provide avenues for intervention to improve outcomes, and should be re-evaluated longitudinally because these associations may become more pronounced with time.
Collapse
Affiliation(s)
- Laura Mercer-Rosa
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Stephen M Paridon
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Mark A Fogel
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Jack Rychik
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Ronn E Tanel
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Huaqing Zhao
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Xuemei Zhang
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Wei Yang
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Justine Shults
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.)
| | - Elizabeth Goldmuntz
- From the Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia (L.M.-R., S.M.P., M.A.F., J.R., E.G.), Department of Clinical Sciences, Temple Clinical Research Center, Temple University School of Medicine (H.Z.), Department of Biostatistics and Epidemiology (X.Z., J.S.), and Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics (W.Y.), Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA; and Division of Pediatric Cardiology, Department of Pediatrics, UCSF Benioff Children's Hospital, UCSF School of Medicine, San Francisco, CA (R.E.T.).
| |
Collapse
|
24
|
|
25
|
Sterrett LE, Ebenroth ES, Query C, Ho J, Montgomery GS, Hurwitz RA, Baye F, Schamberger MS. Why exercise capacity does not improve after pulmonary valve replacement. Pediatr Cardiol 2014; 35:1395-402. [PMID: 24990282 DOI: 10.1007/s00246-014-0942-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Abstract
Optimal timing of pulmonary valve replacement (PVR) for pulmonary regurgitation is a debated topic. It is logical that maximal aerobic capacity (VO2peak) would decline when a PVR is needed, but a diminished VO2peak is not always present before PVR, and previous studies show no improvement in VO2peak after PVR. This study aimed to evaluate changes in resting spirometry from pre- to post-PVR sternotomy, to determine the limiting factors of VO2peak before and after PVR, and to determine whether changes in resting lung function after PVR may explain the lack of improvement in VO2peak after surgery. For 26 patients (age, 19.7 ± 7.8 years) with a history of right ventricular outflow tract revision, the study prospectively evaluated echocardiograms, resting spirometry, and maximal exercise tests before PVR and then an average of 15 months after PVR. Flow volume loops were reviewed by a pulmonologist and categorized as obstructive, restrictive, both obstructive and restrictive, or normal. Exercise tests were interpreted using Eschenbacher's algorithm to determine the primary factors limiting exercise. No change in VO2peak or spirometry after PVR was observed. Before PVR, many patients had abnormal resting lung functions (85 % abnormal), which was unchanged after PVR (86 5 % abnormal). The majority of the patients had a ventilatory limitation to VO2peak before PVR (66.7 %), whereas 28.5 % had a cardiovascular limitation, and 4.8 % had no clear limitation. After PVR, 65.2 % of the patients had a ventilatory limitation, whereas 30.4 % had a cardiovascular limitation, and 4.4 % had no clear limitation to VO2peak. Pulmonary function did not change up to 15 months after surgical PVR. The frequency of pulmonary limitation to VO2peak after PVR did not increase. The effect of pulmonary function on exercise-related symptoms must be considered in this patient population. Improved cardiac hemodynamics are unlikely to improve VO2peak in a primarily pulmonary-limited patient.
Collapse
Affiliation(s)
- Lauren E Sterrett
- Pediatric Cardiology, Riley Hospital for Children at Indiana University School of Medicine, 705 Riley Hospital Drive, RR 127, Indianapolis, IN, 46202, USA,
| | | | | | | | | | | | | | | |
Collapse
|
26
|
O'Meagher S, Munoz PA, Muthurangu V, Robinson PJ, Malitz N, Tanous DJ, Celermajer DS, Puranik R. Mechanisms of maintained exercise capacity in adults with repaired tetralogy of Fallot. Int J Cardiol 2014; 177:178-81. [PMID: 25499372 DOI: 10.1016/j.ijcard.2014.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [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: 04/22/2014] [Revised: 08/21/2014] [Accepted: 09/15/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND The mechanisms whereby cardiac output is augmented with exercise in adult repaired tetralogy of Fallot (TOF) are poorly characterised. METHODS 16 repaired TOF patients (25 ± 7 years of age) and 8 age and sex matched controls (25 ± 4 years of age) underwent cardiopulmonary exercise testing and then real-time cardiac MRI (1.5 T) at rest and whilst exercising within the scanner, aiming for 30% heart rate reserve (Level 1) and 60% heart rate reserve (Level 2), using a custom-built MRI compatible foot pedal device. RESULTS At rest, TOF patients had severely dilated RVs (indexed RV end-diastolic volume: 149 ± 37 mL/m(2)), moderate-severe PR (regurgitant fraction 35 ± 12%), normal RV fractional area change (FAC) (52 ± 7%) and very mildly impaired exercise capacity (83 ± 15% of predicted maximal work rate). Heart rate and RV FAC increased significantly in TOF patients (75 ± 10 vs 123 ± 17 beats per minute, p<0.001; 44 ± 7 vs 51 ± 10%, p=0.025), and similarly in control subjects (70 ± 11 vs 127 ± 12 beats per minute, p<0.001; 49 ± 7 vs 61 ± 9%, p=0.003), when rest was compared to Level 2. PR fraction decreased significantly but only modestly, from rest to Level 2 in TOF patients (37 ± 15 to 31 ± 15%, p=0.002). Pulmonary artery net forward flow was maintained and did not significantly increase from rest to Level 2 in TOF patients (70 ± 19 vs 69 ± 12 mL/beat, p=0.854) or controls (93 ± 9 vs 95 ± 21 mL/beat, p=0.648). CONCLUSIONS During exercise in repaired TOF subjects with dilated RV and free PR, increased total RV output per minute was facilitated by an increase in heart rate, an increase in RV FAC and a decrease in PR fraction.
Collapse
Affiliation(s)
- Shamus O'Meagher
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
| | - Phillip A Munoz
- Royal Prince Alfred Hospital, Department of Respiratory and Sleep Medicine, Sydney, Australia.
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, Centre for Cardiovascular Imaging, London, United Kingdom; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, London, United Kingdom.
| | - Peter J Robinson
- Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia; Westmead Hospital, Department of Cardiology, Sydney, Australia.
| | | | - David J Tanous
- Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia; Westmead Hospital, Department of Cardiology, Sydney, Australia.
| | - David S Celermajer
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
| | - Rajesh Puranik
- The University of Sydney, Faculty of Medicine, Sydney, Australia; Royal Prince Alfred Hospital, Department of Cardiology, Sydney, Australia.
| |
Collapse
|
27
|
Yap J, Tan JL, Le TT, Gao F, Zhong L, Liew R, Tan SY, Tan RS. Assessment of left ventricular preload by cardiac magnetic resonance imaging predicts exercise capacity in adult operated tetralogy of Fallot: a retrospective study. BMC Cardiovasc Disord 2014; 14:122. [PMID: 25245139 PMCID: PMC4177590 DOI: 10.1186/1471-2261-14-122] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2014] [Accepted: 09/16/2014] [Indexed: 05/28/2023] Open
Abstract
Background The optimal timing of pulmonary homograft valve replacement (PVR) is uncertain. Cardiopulmonary exercise testing (CPET) and cardiac magnetic resonance (CMR) are often used to guide the clinical decision for PVR in operated tetralogy of Fallot (TOF) patients with significant pulmonary regurgitation (PR). We aim to study the relationship between exercise capacity and CMR in these patients. Methods The study is a single-centre retrospective analysis of 36 operated TOF patients [median 21.4 (interquartile range 16.4, 26.4) years post-repair; 30 NYHA I, 6 NYHA II; median age 25.2 (interquartile range 19.5-31.7) years, 29 males] with significant PR on CMR who underwent CPET within 15 [median 2.0 (interquartile range 0.8-7.2)] months from CMR. CPET parameters were compared with 30 age- and sex-matched healthy controls [median age 27.8 (interquartile range 21.0-32.8) years; 24 males]. Results Peak systolic blood pressure (177 versus 192 mmHg, p = 0.007), Mets (7.3 versus 9.9, p < 0.001), peak oxygen consumption (VO2max) (29.2 versus 34.5 ml/kg/min, p < 0.001) and peak oxygen pulse (11.0 versus 13.7 ml/beat, p = 0.003) were significantly lower in TOF group versus control. Univariate analyses showed negative correlation between PR fraction and anaerobic threshold. There was a positive correlation between indexed left (LV) and right (RV) ventricular end-diastolic volumes, as well as indexed LV and effective RV stroke volumes, on CMR and VO2max and Mets achieved on CPET. These remained significant after adjustment for age and sex. Conclusions TOF subjects have near normal exercise capacity but significantly lower Mets, VO2max and peak oygen pulse achieved compared to controls. Increased PR fraction in TOF subjects was associated with lower anaerobic threshold. Higher indexed effective RV stroke volume, a measure of LV preload, was associated with higher VO2max and Mets achieved, and may potentially be used as a predictor of exercise capacity.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Ru San Tan
- Department of Cardiology, National Heart Centre Singapore, 5 Hospital Drive, Singapore 169609, Singapore.
| |
Collapse
|
28
|
Babu-Narayan SV, Diller GP, Gheta RR, Bastin AJ, Karonis T, Li W, Pennell DJ, Uemura H, Sethia B, Gatzoulis MA, Shore DF. Clinical Outcomes of Surgical Pulmonary Valve Replacement After Repair of Tetralogy of Fallot and Potential Prognostic Value of Preoperative Cardiopulmonary Exercise Testing. Circulation 2014; 129:18-27. [DOI: 10.1161/circulationaha.113.001485] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Indications for surgical pulmonary valve replacement (PVR) after repair of tetralogy of Fallot have recently been broadened to include asymptomatic patients.
Methods and Results—
The outcomes of PVR in adults after repair of tetralogy of Fallot at a single tertiary center were retrospectively studied. Preoperative cardiopulmonary exercise testing was included. Mortality was the primary outcome measure. In total, 221 PVRs were performed in 220 patients (130 male patients; median age, 32 years; range, 16–64 years). Homografts were used in 117 patients, xenografts in 103 patients, and a mechanical valve in 1 patient. Early (30-day) mortality was 2%. Overall survival was 97% at 1 year, 96% at 3 years, and 92% at 10 years. Survival after PVR in the later era (2005–2010; n=156) was significantly better compared with survival in the earlier era (1993–2004; n=65; 99% versus 94% at 1 year and 98% versus 92% at 3 years, respectively;
P
=0.019). Earlier era patients were more symptomatic preoperatively (
P
=0.036) with a lower preoperative peak oxygen consumption (peak
o
2
;
P
<0.001). Freedom from redo surgical or transcatheter PVR was 98% at 5 years and 96% at 10 years for the whole cohort. Peak
o
2
, E/CO2 slope (ratio of minute ventilation to carbon dioxide production), and heart rate reserve during cardiopulmonary exercise testing predicted risk of early mortality when analyzed with logistic regression analysis; peak
o
2
emerged as the strongest predictor on multivariable analysis (odds ratio, 0.65 per 1 mL·kg
−1
·min
−1
;
P
=0.041).
Conclusions—
PVR after repair of tetralogy of Fallot has a low and improving mortality, with a low need for reintervention. Preoperative cardiopulmonary exercise testing predicts surgical outcome and should therefore be included in the routine assessment of these patients.
Collapse
Affiliation(s)
- Sonya V. Babu-Narayan
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Gerhard-Paul Diller
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Radu R. Gheta
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Anthony J. Bastin
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Theodoros Karonis
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Wei Li
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Dudley J. Pennell
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Hideki Uemura
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Babulal Sethia
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Michael A. Gatzoulis
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| | - Darryl F. Shore
- From the Royal Brompton and Harefield NHS Foundation Trust, London, UK (S.V.B.-N., G.-P.D., R.R.G., A.J.B., T.K., W.L., D.J.P., H.U., B.S., M.A.G., D.F.S.); and National Heart and Lung Institute, Imperial College London and NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and Imperial College London, London, UK (S.V.B.-N., W.L., D.J.P., M.A.G., D.F.S.)
| |
Collapse
|
29
|
O'Meagher S, Choudhary P, Duflou J, Puranik R, Celermajer DS. Causes of death in tetralogy of Fallot in adults--an autopsy study. Int J Cardiol 2013; 168:1547-8. [PMID: 23317550 DOI: 10.1016/j.ijcard.2012.12.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/08/2012] [Indexed: 11/22/2022]
|
30
|
O'Meagher S, Celermajer DS, Puranik R. Preserved stroke volume late after tetralogy repair, despite severe right ventricular dilatation--the author's reply. Heart 2013; 99:1875-6. [PMID: 23958759 DOI: 10.1136/heartjnl-2013-304620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Shamus O'Meagher
- Faculty of Medicine, The University of Sydney, , Sydney, New South Wales, Australia
| | | | | |
Collapse
|
31
|
Masutani S, Senzaki H. Preserved stroke volume late after tetralogy repair, despite severe right ventricular dilatation. Heart 2013; 99:1875. [PMID: 23958760 DOI: 10.1136/heartjnl-2012-303449] [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] [Indexed: 11/04/2022] Open
Affiliation(s)
- Satoshi Masutani
- Department of Pediatric Cardiology, Saitama Medical University, , Kawagoe, Saitama, Japan
| | | |
Collapse
|
32
|
|