Advertisement

Abnormal left ventricular flow organization following repair of tetralogy of Fallot

Published:November 22, 2019DOI:https://doi.org/10.1016/j.jtcvs.2019.11.010

      Abstract

      Background

      Left ventricular intracavitary flow (LVICF) characteristics reflect diastolic function. Right ventricular (RV) volume overload due to pulmonary regurgitation (PR) adversely impacts interventricular interactions and left ventricular (LV) function. This aimed to determine whether patients with PR and mild to moderate RV dilation after repair of tetralogy of Fallot (TOF) repair have abnormal LVICF, and to determine whether RV dilation and biventricular function correlate with LVICF abnormalities.

      Methods

      Patients with repaired TOF with PR (n = 11) and controls (n = 11) underwent LVICF analysis. LV end-diastolic volume was partitioned into 4 flow components: direct flow, retained inflow, delayed ejection flow, and residual volume. Flow components were correlated with indexed biventricular size, function, and LV strain.

      Results

      The TOF patients had reduced direct flow (35% vs 25%; P = .004) and increased residual volume (15% vs 24%; P = .026) compared with controls. Retained inflow and delayed ejection flow did not differ. Reduced direct flow correlated with increased RV end-diastolic volume index (R = 0.44; P = .042), RV end-systolic volume index (R = −0.46; P = .032), reduced RV ejection fraction (R = 0.45; P = .036), and reduced LV circumferential strain (R = 0.52; P = .014). Increased residual volume correlated with increased RV end-systolic volume index (R = 0.52; P = .013), reduced LV ejection fraction (R = −0.54; P = .010), and reduced LV circumferential strain (R = −0.44; P = .040).

      Conclusions

      Patients with repaired TOF with mild to moderate RV dilation have abnormal LV diastolic direct flow and increased recirculating residual volume. These changes correlate with the degree of RV dilation and impaired LV function.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      4D-flow MRI (four-dimensional flow magnetic resonance imaging), bSSFP (balanced steady-state free precession), LV (left ventricular), LVICF (left ventricular intracavitary flow), PR (pulmonary regurgitation), PVR (pulmonary valve replacement), RV (right ventricular), TOF (tetralogy of Fallot)
      To read this article in full you will need to make a payment

      References

        • Valente A.M.
        • Geva T.
        How to image repaired tetralogy of Fallot.
        Circ Cardiovasc Imaging. 2017; 10: e004270
        • Apitz C.
        • Webb G.D.
        • Redington A.N.
        Tetralogy of Fallot.
        Lancet. 2009; 374: 1462-1471
        • Chen C.A.
        • Dusenbery S.M.
        • Valente A.M.
        • Powell A.J.
        • Geva T.
        Myocardial ECV fraction assessed by CMR is associated with type of hemodynamic load and arrhythmia in repaired tetralogy of Fallot.
        JACC Cardiovasc Imaging. 2016; 9: 1-10
        • Jing L.
        • Haggerty C.M.
        • Suever J.D.
        • Alhadad S.
        • Prakash A.
        • Cecchin F.
        • et al.
        Patients with repaired tetralogy of Fallot suffer from intra- and inter-ventricular cardiac dyssynchrony: a cardiac magnetic resonance study.
        Eur Heart J Cardiovasc Imaging. 2014; 15: 1333-1343
        • Chen S.S.
        • Keegan J.
        • Dowsey A.W.
        • Ismail T.
        • Wage R.
        • Li W.
        • et al.
        Cardiovascular magnetic resonance tagging of the right ventricular free wall for the assessment of long axis myocardial function in congenital heart disease.
        J Cardiovasc Magn Reson. 2011; 13: 80
        • Latus H.
        • Binder W.
        • Kerst G.
        • Hofbeck M.
        • Sieverding L.
        • Apitz C.
        Right ventricular-pulmonary arterial coupling in patients after repair of tetralogy of Fallot.
        J Thorac Cardiovasc Surg. 2013; 146: 1366-1372
        • Friedberg M.K.
        • Fernandes F.P.
        • Roche S.L.
        • Grosse-Wortmann L.
        • Manlhiot C.
        • Fackoury C.
        • et al.
        Impaired right and left ventricular diastolic myocardial mechanics and filling in asymptomatic children and adolescents after repair of tetralogy of Fallot.
        Eur Heart J Cardiovasc Imaging. 2012; 13: 905-913
        • Kempny A.
        • Diller G.P.
        • Orwat S.
        • Kaleschke G.
        • Kerckhoff G.
        • ACh Bunck
        • et al.
        Right ventricular-left ventricular interaction in adults with tetralogy of Fallot: a combined cardiac magnetic resonance and echocardiographic speckle tracking study.
        Int J Cardiol. 2012; 154: 259-264
        • Geva T.
        Indications for pulmonary valve replacement in repaired tetralogy of Fallot: the quest continues.
        Circulation. 2013; 128: 1855-1857
        • Diller G.P.
        • Kempny A.
        • Liodakis E.
        • Alonso-Gonzalez R.
        • Inuzuka R.
        • Uebing A.
        • et al.
        Left ventricular longitudinal function predicts life-threatening ventricular arrhythmia and death in adults with repaired tetralogy of Fallot.
        Circulation. 2012; 125: 2440-2446
        • Geva T.
        Repaired tetralogy of Fallot: the roles of cardiovascular magnetic resonance in evaluating pathophysiology and for pulmonary valve replacement decision support.
        J Cardiovasc Magn Reson. 2011; 13: 9
        • Geva T.
        • Gauvreau K.
        • Powell A.J.
        • Cecchin F.
        • Rhodes J.
        • Geva J.
        • et al.
        Randomized trial of pulmonary valve replacement with and without right ventricular remodeling surgery.
        Circulation. 2010; 122: S201-S208
        • Sjöberg P.
        • Töger J.
        • Hedström E.
        • Arvidsson P.
        • Heiberg E.
        • Arheden H.
        • et al.
        Altered biventricular hemodynamic forces in patients with repaired tetralogy of Fallot and right ventricular volume overload because of pulmonary regurgitation.
        Am J Physiol Heart Circ Physiol. 2018; 315: H1691-H1702
        • Sjöberg P.
        • Bidhult S.
        • Bock J.
        • Heiberg E.
        • Arheden H.
        • Gustafsson R.
        • et al.
        Disturbed left and right ventricular kinetic energy in patients with repaired tetralogy of Fallot: pathophysiological insights using 4D-flow MRI.
        Eur Radiol. 2018; 28: 4066-4076
        • Moon T.J.
        • Choueiter N.
        • Geva T.
        • Valente A.M.
        • Gauvreau K.
        • Harrild D.M.
        Relation of biventricular strain and dyssynchrony in repaired tetralogy of Fallot measured by cardiac magnetic resonance to death and sustained ventricular tachycardia.
        Am J Cardiol. 2015; 115: 676-680
        • Eriksson J.
        • Carlhäll C.J.
        • Dyverfeldt P.
        • Engvall J.
        • Bolger A.F.
        • Ebbers T.
        Semi-automatic quantification of 4D left ventricular blood flow.
        J Cardiovasc Magn Reson. 2010; 12: 9
        • Eriksson J.
        • Dyverfeldt P.
        • Engvall J.
        • Bolger A.F.
        • Ebbers T.
        • Carlhäll C.J.
        Quantification of presystolic blood flow organization and energetics in the human left ventricle.
        Am J Physiol Heart Circ Physiol. 2011; 300: H2135-H2141
        • Pedrizzetti G.
        • La Canna G.
        • Alfieri O.
        • Tonti G.
        The vortex–an early predictor of cardiovascular outcome?.
        Nat Rev Cardiol. 2014; 11: 545-553
        • Sengupta P.P.
        • Pedrizzetti G.
        • Kilner P.J.
        • Kheradvar A.
        • Ebbers T.
        • Tonti G.
        • et al.
        Emerging trends in CV flow visualization.
        JACC Cardiovasc Imaging. 2012; 5: 305-316
        • Stoll V.M.
        • Hess A.T.
        • Rodgers C.T.
        • Bissell M.M.
        • Dyverfeldt P.
        • Ebbers T.
        • et al.
        Left ventricular flow analysis.
        Circ Cardiovasc Imaging. 2019; 12: e008130
        • Schäfer M.
        • Humphries S.
        • Stenmark K.R.
        • Kheyfets V.O.
        • Buckner J.K.
        • Hunter K.S.
        • et al.
        4D-flow cardiac magnetic resonance-derived vorticity is sensitive marker of left ventricular diastolic dysfunction in patients with mild-to-moderate chronic obstructive pulmonary disease.
        Eur Heart J Cardiovasc Imaging. 2018; 19: 415-424
        • Schäfer M.
        • Browne L.P.
        • Morgan G.J.
        • Barker A.J.
        • Fonseca B.
        • Ivy D.D.
        • et al.
        Reduced proximal aortic compliance and elevated wall shear stress after early repair of tetralogy of Fallot.
        J Thorac Cardiovasc Surg. 2018; 156: 2239-2249
        • Schäfer M.
        • Browne L.P.
        • von Alvensleben J.C.
        • Mitchell M.B.
        • Morgan G.J.
        • Ivy D.D.
        • et al.
        Ventricular interactions and electromechanical dyssynchrony after Ross and Ross-Konno operations.
        J Thorac Cardiovasc Surg. 2019; 158: 509-517
        • Fredriksson A.G.
        • Zajac J.
        • Eriksson J.
        • Dyverfeldt P.
        • Bolger A.F.
        • Ebbers T.
        • et al.
        4-D blood flow in the human right ventricle.
        Am J Physiol Heart Circ Physiol. 2011; 301: H2344-H2350
        • Schäfer M.
        • Browning J.
        • Schroeder J.D.
        • Shandas R.
        • Kheyfets V.O.
        • Buckner J.K.
        • et al.
        Vorticity is a marker of diastolic ventricular interdependency in pulmonary hypertension.
        Pulm Circ. 2016; 6: 46-54
        • Abe H.
        • Caracciolo G.
        • Kheradvar A.
        • Pedrizzetti G.
        • Khandheria B.K.
        • Narula J.
        • et al.
        Contrast echocardiography for assessing left ventricular vortex strength in heart failure: a prospective cohort study.
        Eur Heart J Cardiovasc Imaging. 2013; 14: 1049-1060
        • Pedrizzetti G.
        • Claus P.
        • Kilner P.J.
        • Nagel E.
        Principles of cardiovascular magnetic resonance feature tracking and echocardiographic speckle tracking for informed clinical use.
        J Cardiovasc Magn Reson. 2016; 18: 51
        • Hong G.R.
        • Pedrizzetti G.
        • Tonti G.
        • Li P.
        • Wei Z.
        • Kim J.K.
        • et al.
        Characterization and quantification of vortex flow in the human left ventricle by contrast echocardiography using vector particle image velocimetry.
        JACC Cardiovasc Imaging. 2008; 1: 705-717
        • Jeong D.
        • Anagnostopoulos P.V.
        • Roldan-Alzate A.
        • Srinivasan S.
        • Schiebler M.L.
        • Wieben O.
        • et al.
        Ventricular kinetic energy may provide a novel noninvasive way to assess ventricular performance in patients with repaired tetralogy of Fallot.
        J Thorac Cardiovasc Surg. 2015; 149: 1339-1347
        • Stoll V.M.
        • Loudon M.
        • Eriksson J.
        • Bissell M.M.
        • Dyverfeldt P.
        • Ebbers T.
        • et al.
        Test-retest variability of left ventricular 4D flow cardiovascular magnetic resonance measurements in healthy subjects.
        J Cardiovasc Magn Reson. 2018; 20: 15