Adverse Left Ventricular Mechanics in Adults With Repaired Tetralogy of Fallot

doi:10.1016/j.amjcard.2008.09.101

The American Journal of Cardiology

Volume 103, Issue 3, 1 February 2009, Pages 420-425

https://doi.org/10.1016/j.amjcard.2008.09.101 Get rights and content

Left ventricular (LV) dysfunction is a predictor of adverse outcomes in patients with repaired tetralogy of Fallot (TOF). However, the mechanisms for LV dysfunction are not well understood. The aim of the study was to determine whether the prolonged QRS duration of right branch bundle block was associated with adverse LV mechanics. Seventy-five patients (mean age 31 ± 2 years) with repaired TOF were studied. LV and right ventricular (RV) volumes and ejection fractions (EFs) were assessed using cardiac magnetic resonance imaging. Vector velocity imaging was used to assess longitudinal strain and intraventricular dyssynchrony. Prolonged QRS duration was associated with increased RV and LV dimensions (p = 0.01) and decreased function (RVEF r = −0.60, p <0.001 and LVEF r = −0.77, p <0.001). In addition, prolonged QRS duration was associated with heterogeneous ventricular mechanical activation and reduced strain in the lateral and septal left ventricle walls. Degree of intraventricular dyssynchrony correlated with LVEF (r = −0.59, p <0.001), QRS duration (r = 0.74, p <0.001), and septal strain (r = 0.70, p <0.001). In conclusion, LV dysfunction and dyssynchrony were observed in patients with TOF and were associated with QRS duration. It was possible that abnormal LV mechanics in combination with RV dysfunction may explain the relation between QRS duration and adverse cardiac outcomes.

Section snippets

Methods

Subjects with TOF were identified from the Toronto Congenital Cardiac Centre for Adults (Toronto, Canada) computerized database. Routine magnetic resonance imaging (MRI) in patients with TOF has become standard practice at our institution. Imaging studies were typically performed every 3 to 4 years. Echocardiograms were obtained on an annual basis. Patients were included who fulfilled all the criteria of (1) repaired TOF >5 years after complete repair, (2) completion of a cardiac MRI

Results

The study cohort consisted of 75 patients with repaired TOF (51% males). Thirty-seven patients had an initial shunt (35 Blalock-Taussig shunts and 2 Waterston shunts). All patients underwent intracardiac repair (mean age at repair 6 ± 4 years, range 1 to 30), 39 of whom had a transannular patch as part of the surgical repair. In 10 patients, surgical details were insufficient to determine whether the patient had a transannular patch. Twenty patients had a pulmonary valve implant. No patient had

Discussion

This study, using a comprehensive assessment of magnetic resonance–derived parameters of global biventricular performance and echocardiographic measures (velocity vector imaging) of regional function, provided further evidence of important ventricular–ventricular associations late after repair of TOF and some insight into the potential mechanisms of this interaction. Abnormalities of RV and LV global function were interrelated and associated with abnormal mechanoelectric interactions, manifest

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Left ventricular strain and fibrosis in adults with repaired tetralogy of Fallot: A case-control study
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Citation Excerpt :
Our study confirms that both LV-ECV and global systolic strain are abnormal compared to controls and are associated with cardiac chamber size and function and clinical outcome. Previous studies have shown associations between these measures and clinical events such as arrhythmias, LV systolic and diastolic dysfunction and death, though with some mixed results [2–4,7–10]. Therefore, strain and fibrosis both appear to demonstrate different myocardial characteristics that may both play a role in the natural history of rTOF.
Left ventricular (LV) systolic dysfunction and myocardial fibrosis have prognostic implications in repaired tetralogy of Fallot (rTOF), but their relationship with myocardial strain is not well understood. We evaluated systolic strain and fibrosis (extracellular volume fraction, ECV) of the left ventricle (LV) using feature tracking with magnetic resonance and determine their association with each other and clinical outcome.
Adults with rTOF and age-matched controls underwent CMR to measure LV-ECV. Feature-tracking was used to quantify radial, circumferential, and longitudinal strain in both 2 and 3 dimensions. Clinical events (death, arrhythmia and heart-failure hospitalization) were obtained through chart review. Associations between strain, ECV and clinical events were explored.
48 rTOF subjects (age 40.5 ± 14.3, 42% female) and 20 healthy controls were included. Both LV 2D and 3D global circumferential strain (GCS) and global longitudinal strain (GLS) were lower in rTOF subjects (p ≤0.01 for all). There was no association between strain and LV-ECV. Strain parameters correlated with ventricular volumes and function. After a median follow-up of 8.5 years (range 1–10.9 years) there were 5 deaths, 6 hospitalizations and 9 new arrhythmias. By multivariate Cox-regression, GLS was an independent predictor of both hospitalization and death, whereas LV-ECV was an independent predictor of arrhythmia.
While both LV strain abnormalities and fibrosis are present in rTOF, they are associated with different types of clinical outcome, and not to each other. The findings suggest that these measures reflect different long-term adverse adaptations to abnormal hemodynamics.
Echocardiographic assessment of ventricular function: Conventional and advanced technologies and their clinical applications
2020, Progress in Pediatric Cardiology
Echocardiogram is the first-line and most used noninvasive imaging diagnostic modality and is convenient and reliable in its assessment of ventricular function in pediatrics. Ventricular function is an important physiological parameter representing myocardial performance in response to overall hemodynamic status. Here, we introduce basic principles of conventional echocardiography and advanced echocardiographic technology, including tissue Doppler imaging, 3-dimensional echocardiogram, and speckled tracking echocardiography. Then, we overview clinical applications of these methods in assessing ventricular function in pediatrics, including single ventricle after staged surgical palliation, right ventricular dysfunction in pulmonary hypertension, and ventricular-ventricular interactions in various heart disease. With multimodality approaches, the advantages and limitations of echocardiographic assessment of ventricular function are discussed.
Ventricular Myocardial Deformation Imaging of Patients with Repaired Tetralogy of Fallot
2020, Journal of the American Society of Echocardiography
In patients with repaired tetralogy of Fallot (TOF), dysfunction of the right and left ventricles remains an important issue. Adverse right ventricular (RV) remodeling has been related to RV dilation secondary to pulmonary regurgitation, electromechanical dyssynchrony, and myocardial fibrosis. Left ventricular (LV) dysfunction is attributed among other factors to altered ventricular-ventricular interaction. Advancements in echocardiography and cardiac magnetic resonance imaging have enabled direct interrogation of myocardial deformation of both ventricles in terms of myocardial strain and strain rate. Emerging evidence suggests that myocardial deformation imaging may provide incremental information for clinical use. In children and adults with repaired TOF, there is a growing body of literature on the use of myocardial deformation imaging in the assessment of ventricular mechanics and its clinical and prognostic values. The present review aims to provide an overview of impairment in RV and LV mechanics, associations between RV and LV deformation, changes in ventricular deformation after pulmonary valve replacement, and associations between measures of RV and LV deformation and outcomes and to highlight the clinical translational potential of myocardial deformation imaging in patients with repaired TOF.
Cardiac Ventricular Contractile Responses to Chronically Increased Afterload Secondary to Right Ventricular Outflow Obstruction in Patients With Tetralogy of Fallot
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We examined the adaptive mechanism of the pulmonary ventricle (PV) in response to increased afterload secondary to pulmonary stenosis in tetralogy of Fallot (TOF, n = 47) and congenitally corrected transposition of the great arteries (cCTGA, n = 18), where the PV is morphologically different. We also elucidated the effects of such adaptation on systemic ventricular (SV) function. PV contractility, assessed by dp/dt_max, showed significant positive correlations with PV pressure (r = 0.82, p <0.01 for TOF and r = 0.78, p <0.01 for cCTGA) and pulmonary-to-systemic ventricular pressure ratio (r = 0.70, p <0.01 for TOF and r = 0.76, p <0.01 for cCTGA) in patients with both TOF and cCTGA. Notably, the slopes of these correlations were significantly higher in cCTGA than in TOF (p <0.01), suggesting enhanced contractile responses in cCTGA. Moreover, SV dp/dt_max showed significant positive correlations with PV dp/dt_max in patients with both TOF and cCTGA (r = 0.67, p <0.01 and r = 0.61, p <0.01, respectively), indicating positive ventricular–ventricular interaction. In this relationship, the slopes of correlations were significantly higher in TOF than in cCTGA (p = 0.024). These results, indicating different behaviors of PV contractile physiology and its interaction with the SV, may have important therapeutic implications when considering medical, catheter, and surgical interventions for pulmonary stenosis in these diseases. The results may also offer the potential for a new approach for improvement of prognosis, especially in cCTGA.

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: Dr. Tzemos was supported by a research postgraduate fellowship from the University of Toronto, Toronto, Canada. Dr. Silversides was supported by a grant from the Heart and Stroke Foundation of Ontario, Toronto, Ontario, Canada.

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Congenital heart diseaseAdverse Left Ventricular Mechanics in Adults With Repaired Tetralogy of Fallot

Section snippets

Methods

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

Heart Rhythm

Am J Cardiol

Congenital heart disease
Adverse Left Ventricular Mechanics in Adults With Repaired Tetralogy of Fallot