Zusammenfassung
Einleitung
Im langfristigen Verlauf von Patienten mit Vorhofumkehroperation bei D-Transposition der großen Arterien ist neben rechtsventrikulären Rhythmusstörungen eine Insuffizienz des morphologisch rechten Ventrikels in Systemposition mit Trikuspidalklappeninsuffizienz zu erwarten. Die Beurteilung des myokardialen kontraktilen Verhaltens mit der herkömmlichen Echokardiographie ist aufgrund der deutlich veränderten Morphologie des morphologisch rechten Systemventrikels limitiert. Der Einsatz der Gewebedoppler-Echokardiographie inklusive Strain und Strain Rate ermöglicht einen neuen Zugang zur quantitativen Myokard-Funktionsanalyse. Ziel dieser Studie war es, das Geschwindigkeitsverhalten definierter Myokardregionen und deren kontraktile Funktion des systemischen rechten Ventrikels bei Patienten mit D-Transposition der großen Arterien nach Vorhofumkehroperation zu untersuchen und einer herzgesunden Vergleichsgruppe gegenüber zu stellen.
Patienten und Methode
24 Patienten mit Vorhofumkehroperation bei D-Transposition der großen Arterien wurden 16,9 Jahre nach der Operation mit einem medianen Alter von 21,3 Jahren (13–31) mittels Gewebedoppler-Echokardiographie untersucht und mit 22 herzgesunden Personen mit einem medianen Alter von 21,5 Jahren (3–41) verglichen. Im apikalen Vierkammerblick wurde an einem klappennahen Messpunkt der rechtsventrikulären freien Wand die systolische (SystT) und diastolischen (ET, AT) Maximalgeschwindigkeiten sowie die ET/AT Ratio in longitudinaler Richtung bestimmt, der während der isovolumetrischen Akzeleration auftretende Geschwindigkeitspeak registriert und der IVA-Index als Quotient zwischen isovolumetrischem Geschwindigkeitspeak und isovolumetrischer Akzelerationszeit berechnet. Außerdem wurde der myokardiale Strain und die systolischen und diastolischen Strain Rates der basalen, mittleren und apikalen Region der rechtsventrikulären freien Wand untersucht. Die erhobenen Daten des morphologisch rechten Systemventrikels wurden mit denen des linken und rechten Ventrikels der Kontrollgruppe verglichen.
Ergebnisse
Die systolischen maximalen Geschwindigkeiten des morphologisch rechten Systemventrikels waren signifikant gegenüber einem normalen Pulmonal- bzw. Systemventrikel reduziert. Der IVA-Index in der Patientengruppe war im Gegensatz zu dem eines normalen subpulmonalen rechten Ventrikel signifi kant vermindert, nicht aber im Vergleich mit den Werten eines normalen systemischen linken Ventrikels. Hingegen waren die Strain und Strain-Rate-Parameter in den analysierten Regionen größtenteils hoch signifikant gegenüber den Werten des normalen rechten und linken Ventrikels reduziert.
Schlussfolgerung
Die Gewebedopplerechokardiographie ist eine viel versprechende Methode zur Evaluation der regionalen myokardialen kontraktilen Funktion des morphologisch rechten Systemventrikels bei Patienten nach Vorhofumkehroperation bei D-Transposition der großen Arterien. Die präsystolische, systolische und diastolische regionale ventrikuläre Funktion war im morphologisch rechten Systemventrikel eingeschränkt. Weitere vergleichende Untersuchungen mit anderen quantitativen Parametern der globalen und regionalen Funktion sind nötig, um die Zuverlässigkeit der Gewebedopplerechokardiographie in der Beurteilung der globalen rechtsventrikulären Funktion zu evaluieren.
Summary
Introduction
The long-term follow-up of patients with D-transposition of the great arteries after atrial switch operation shows specific problems such as tricuspid valve insufficiency, rhythm disturbances and failure of the morphologic right ventricle in systemic position. Assessment of the myocardial contractility of the subaortic right ventricle by conventional echocardiography is limited. The usage of tissue Doppler echocardiography with strain combined with strain rate imaging provides a new approach for quantitative analysis of longitudinal myocardial function. The aim of this study was to assess patterns of wall motion and regional contractile function of the systemic right ventricle in patients after atrial switch operation for D-transposition of the great arteries and to compare them to those of normal subjects.
Patients and methods
Twenty-four patients with Dtransposition of the great arteries after atrial switch operation with a mean age of 21.3 (range, 13 to 31) years and a postoperative period of 16.9 years were examined and compared to 22 control individuals with a mean age of 21.5 (range, 3 to 43) years. Tissue Doppler studies were obtained from apical 4- chamber view to determine regional systolic (SystT) and diastolic (ET, AT) velocities as well as ET/AT ratio at the basal free wall. The presystolic isovolumic contraction peak was assessed and the ratio of the presystolic peak velocity to the isovolumic acceleration time as the IVA index was calculated. Strain and peak systolic and diastolic strain rates were assessed on basal, middle and apical segments of the right ventricular free wall. Data obtained from the morphologic right systemic ventricle in patients were compared to those derived from the left and the right ventricle in controls.
Results
The right ventricular free wall systolic velocities were significantly reduced in patients compared to velocities obtained from the normal right and left ventricle. On the other hand, the IVA index was only reduced in patients compared to the IVA index in the normal subpulmonary right ventricle. Compared to data obtained from the normal systemic left ventricle, the IVA index in patients was not significantly different. In contrast, strain and strain rate parameters in all analyzed segments mostly showed a highly significant reduction compared to normal right and left ventricular data.
Conclusion
Tissue Doppler echocardiography is a promising tool for the evaluation of regional myocardial contractile function of the morphologic right systemic ventricle in patients following atrial switch operation for D-transposition of the great arteries. Presystolic, systolic and diastolic regional ventricular function was reduced in the systemic right ventricle. However, further comparative studies using other quantitative parameters of global and regional myocardial function derived from cardiac catheterization or MRI should be performed in order to evaluate the reliability of tissue Doppler echocardiography for the assessment of global right ventricular function in these patients.
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Rentzsch, A., Abd El Rahman, M.Y., Hui, W. et al. Assessment of myocardial function of the systemic right ventricle in patients with D-transposition of the great arteries after atrial switch operation by tissue Doppler echocardiography. ZS Kardiologie 94, 524–531 (2005). https://doi.org/10.1007/s00392-005-0258-6
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DOI: https://doi.org/10.1007/s00392-005-0258-6
Schlüsselwörter
- D-Transposition der großen Arterien
- Rechtsventrikuläre Dysfunktion
- Gewebedoppler-
- Echokardiographie
- Strain/Strain Rate