Advertisement

Imposition of Fontan physiology: Effects on strain and global measures of ventricular function

Published:February 16, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.02.034

      Abstract

      Objective

      We sought to evaluate contractile function in single-ventricle patients before and after imposition of Fontan physiology.

      Methods

      Single right ventricle (SRV; n = 38) and single left ventricle (SLV; n = 11) patients underwent cardiac magnetic resonance imaging pre and post Fontan operation. Global radial strain (GRS), global circumferential strain (GCS), and global longitudinal strain were measured along with ejection fraction (EF) and atrioventricular valve regurgitation (AVVR).

      Results

      Age at cardiac magnetic resonance imaging before the Fontan operation was 3.1 ± 1.3 years and after the Fontan procedure was 5.8 ± 2.7 years. There were no significant EF differences between SRV and SLV patients before and after the Fontan procedure, and EF did not deteriorate significantly after the Fontan operation. GRS was significantly lower for SRV patients than for SLV patients before (24.3% vs 32.1%; P = .048) and after (21.8% vs 29.7%; P = .045) the Fontan procedure. GRS and GCS of the SRV patients deteriorated significantly after the Fontan operation (GRS, P = .01; GCS, P = .009). Strains showed positive correlations before and after the Fontan operation with positive correlations among each strain. Within all patients, strains correlated positively with EF. Strains and EF negatively correlated with AVVR (GRS P = .03, r = −0.22; GCS P = .03, r = −0.23; EF P < .001, r = −0.37).

      Conclusions

      Strains were lower for SRV than for SLV patients before and after the Fontan operation and deteriorated after the Fontan operation. Our study suggests that strain measures might detect ventricular deterioration earlier than EF. Because strains before and after the Fontan operation were positively correlated, and negatively correlated with AVVR, the early institution of myocardial protective therapy including AVVR management, especially for SRV patients, might have benefit.

      Key Words

      Abbreviations and Acronyms:

      AVVR (atrioventricular valve regurgitation), CMR (cardiac magnetic resonance imaging), 4cv (4-chamber view), EDV (end-diastolic volume), EF (ejection fraction), ESV (end-systolic volume), ESVi (indexed end-systolic volume), GCS (global circumferential strain), GLS (global longitudinal strain), GRS (global radial strain), HR (heart rate), sax (short axis), SLV (single left ventricle), SRV (single right ventricle)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Thoracic and Cardiovascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Gewillig M.
        The Fontan circulation.
        Heart. 2005; 91: 839-846
        • Ghelani S.J.
        • Colan S.D.
        • Azcue N.
        • Keenan E.M.
        • Harrild D.M.
        • Powell A.J.
        • et al.
        Impact of ventricular morphology on fiber stress and strain in Fontan patients.
        Circ Cardiovasc Imaging. 2018; 11: e006738
        • Sundareswaran K.S.
        • Kanter K.R.
        • Kitajima H.D.
        • Krishnankutty R.
        • Sabatier J.F.
        • Parks W.J.
        • et al.
        Impaired power output and cardiac index with hypoplastic left heart syndrome: a magnetic resonance imaging study.
        Ann Thorac Surg. 2006; 82 (discussion: 1275-67): 1267-1275
        • Gentles T.L.
        • Mayer Jr., J.E.
        • Gauvreau K.
        • Newburger J.W.
        • Lock J.E.
        • Kupferschmid J.P.
        • et al.
        Fontan operation in five hundred consecutive patients: factors influencing early and late outcome.
        J Thorac Cardiovasc Surg. 1997; 114: 376-391
        • Hosein R.B.
        • Clarke A.J.
        • McGuirk S.P.
        • Griselli M.
        • Stumper O.
        • De Giovanni J.V.
        • et al.
        Factors influencing early and late outcome following the Fontan procedure in the current era. The “Two Commandments”?.
        Eur J Cardiothorac Surg. 2007; 31 (discussion: 353): 344-352
        • Altmann K.
        • Printz B.F.
        • Solowiejczky D.E.
        • Gersony W.M.
        • Quaegebeur J.
        • Apfel H.D.
        Two-dimensional echocardiographic assessment of right ventricular function as a predictor of outcome in hypoplastic left heart syndrome.
        Am J Cardiol. 2000; 86: 964-968
        • Simsic J.M.
        • Bradley S.M.
        • Stroud M.R.
        • Atz A.M.
        Risk factors for interstage death after the Norwood procedure.
        Pediatr Cardiol. 2005; 26: 400-403
        • Menon S.C.
        • Dearani J.A.
        • Cetta F.
        Long-term outcome after atrioventricular valve surgery following modified Fontan operation.
        Cardiol Young. 2011; 21: 83-88
        • Mertens L.L.
        • Friedberg M.K.
        Imaging the right ventricle–current state of the art.
        Nat Rev Cardiol. 2010; 7: 551-563
        • Bellsham-Revell H.R.
        • Tibby S.M.
        • Bell A.J.
        • Witter T.
        • Simpson J.
        • Beerbaum P.
        • et al.
        Serial magnetic resonance imaging in hypoplastic left heart syndrome gives valuable insight into ventricular and vascular adaptation.
        J Am Coll Cardiol. 2013; 61: 561-570
        • Nakamura Y.
        • Yagihara T.
        • Kagisaki K.
        • Hagino I.
        • Kobayashi J.
        Ventricular performance in long-term survivors after Fontan operation.
        Ann Thorac Surg. 2011; 91: 172-180
        • 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
        • Kempny A.
        • Diller G.P.
        • Orwat S.
        • Kaleschke G.
        • Kerckhoff G.
        • Bunck A.
        • 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
        • Friedberg M.K.
        • Mertens L.
        Tissue velocities, strain, and strain rate for echocardiographic assessment of ventricular function in congenital heart disease.
        Eur J Echocardiogr. 2009; 10: 585-593
        • Bijnens B.H.
        • Cikes M.
        • Claus P.
        • Sutherland G.R.
        Velocity and deformation imaging for the assessment of myocardial dysfunction.
        Eur J Echocardiogr. 2009; 10: 216-226
        • Petko C.
        • Uebing A.
        • Furck A.
        • Rickers C.
        • Scheewe J.
        • Kramer H.H.
        Changes of right ventricular function and longitudinal deformation in children with hypoplastic left heart syndrome before and after the Norwood operation.
        J Am Soc Echocardiogr. 2011; 24: 1226-1232
        • Kaneko S.
        • Khoo N.S.
        • Smallhorn J.F.
        • Tham E.B.
        Single right ventricles have impaired systolic and diastolic function compared to those of left ventricular morphology.
        J Am Soc Echocardiogr. 2012; 25: 1222-1230
        • Koopman L.P.
        • Geerdink L.M.
        • Bossers S.S.M.
        • Duppen N.
        • Kuipers I.M.
        • Ten Harkel A.D.
        • et al.
        Longitudinal myocardial deformation does not predict single ventricle ejection fraction assessed by cardiac magnetic resonance imaging in children with a total cavopulmonary connection.
        Pediatr Cardiol. 2018; 39: 283-293
        • Kawashima Y.
        • Kitamura S.
        • Matsuda H.
        • Shimazaki Y.
        • Nakano S.
        • Hirose H.
        Total cavopulmonary shunt operation in complex cardiac anomalies. A new operation.
        J Thorac Cardiovasc Surg. 1984; 87: 74-81
        • Fogel M.A.
        • Pawlowski T.W.
        • Whitehead K.K.
        • Harris M.A.
        • Keller M.S.
        • Glatz A.C.
        • et al.
        Cardiac magnetic resonance and the need for routine cardiac catheterization in single ventricle patients prior to Fontan: a comparison of 3 groups: pre-Fontan CMR versus cath evaluation.
        J Am Coll Cardiol. 2012; 60: 1094-1102
        • R Core Team
        R: A Language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2019
        • Suga H.
        • Sagawa K.
        Instantaneous pressure-volume relationships and their ratio in the excised, supported canine left ventricle.
        Circ Res. 1974; 35: 117-126
        • Sunagawa K.
        • Maughan W.L.
        • Burkhoff D.
        • Sagawa K.
        Left ventricular interaction with arterial load studied in isolated canine ventricle.
        Am J Physiol. 1983; 245: H773-H780
        • Nahum J.
        • Bensaid A.
        • Dussault C.
        • Macron L.
        • Clemence D.
        • Bouhemad B.
        • et al.
        Impact of longitudinal myocardial deformation on the prognosis of chronic heart failure patients.
        Circ Cardiovasc Imaging. 2010; 3: 249-256
        • Kalam K.
        • Otahal P.
        • Marwick T.H.
        Prognostic implications of global LV dysfunction: a systematic review and meta-analysis of global longitudinal strain and ejection fraction.
        Heart. 2014; 100: 1673-1680
        • Sengelov M.
        • Jorgensen P.G.
        • Jensen J.S.
        • Bruun N.E.
        • Olsen F.J.
        • Fritz-Hansen T.
        • et al.
        Global longitudinal strain is a superior predictor of all-cause mortality in heart failure with reduced ejection fraction.
        JACC Cardiovasc Imaging. 2015; 8: 1351-1359
        • Kato A.
        • Riesenkampff E.
        • Yim D.
        • Yoo S.J.
        • Seed M.
        • Grosse-Wortmann L.
        Pediatric Fontan patients are at risk for myocardial fibrotic remodeling and dysfunction.
        Int J Cardiol. 2017; 240: 172-177
        • Urschel C.W.
        • Covell J.W.
        • Sonnenblick E.H.
        • Ross Jr., J.
        • Braunwald E.
        Myocardial mechanics in aortic and mitral valvular regurgitation: the concept of instantaneous impedance as a determinant of the performance of the intact heart.
        J Clin Invest. 1968; 47: 867-883
        • Enriquez-Sarano M.
        • Tajik A.J.
        • Schaff H.V.
        • Orszulak T.A.
        • Bailey K.R.
        • Frye R.L.
        Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation.
        Circulation. 1994; 90: 830-837
        • Driscoll D.J.
        • Offord K.P.
        • Feldt R.H.
        • Schaff H.V.
        • Puga F.J.
        • Danielson G.K.
        Five- to fifteen-year follow-up after Fontan operation.
        Circulation. 1992; 85: 469-496
        • Hu L.
        • Sun A.
        • Guo C.
        • Ouyang R.
        • Wang Q.
        • Yao X.
        • et al.
        Assessment of global and regional strain left ventricular in patients with preserved ejection fraction after Fontan operation using a tissue tracking technique.
        Int J Cardiovasc Imaging. 2019; 35: 153-160
        • Rosner A.
        • Khalapyan T.
        • Pedrosa J.
        • Dalen H.
        • McElhinney D.B.
        • Friedberg M.K.
        • et al.
        Ventricular mechanics in adolescent and adult patients with a Fontan circulation: relation to geometry and wall stress.
        Echocardiography. 2018; 35: 2035-2046
        • Moiduddin N.
        • Texter K.M.
        • Zaidi A.N.
        • Hershenson J.A.
        • Stefaniak C.
        • Hayes J.
        • et al.
        Two-dimensional speckle strain and dyssynchrony in single left ventricles vs. normal left ventricles.
        Congenit Heart Dis. 2010; 5: 579-586
        • Ortega M.
        • Triedman J.K.
        • Geva T.
        • Harrild D.M.
        Relation of left ventricular dyssynchrony measured by cardiac magnetic resonance tissue tracking in repaired tetralogy of Fallot to ventricular tachycardia and death.
        Am J Cardiol. 2011; 107: 1535-1540
        • Ishizaki U.
        • Nagao M.
        • Shiina Y.
        • Inai K.
        • Mori H.
        • Takahashi T.
        • et al.
        Global strain and dyssynchrony of the single ventricle predict adverse cardiac events after the Fontan procedure: analysis using feature-tracking cine magnetic resonance imaging.
        J Cardiol. 2019; 73: 163-170

      Linked Article

      • Commentary: Maybe it is better to be a lefty
        The Journal of Thoracic and Cardiovascular SurgeryVol. 162Issue 6
        • Preview
          The Fontan operation is often the final planned procedure in the staged palliation of functional single-ventricle heart disease, but its effect on ventricular function remains poorly understood. The fascinating study in the current issue by Shiraga and colleagues1 attempts to answer 2 questions about single ventricles and the Fontan: (1) How does the Fontan operation affect ventricular function and (2) are there differences between single right (SRV) and single left ventricular (SLV) function? To examine these questions, the authors measured myocardial strain by feature tracking analysis of cardiac magnetic resonance images pre- and post-Fontan in a group of single-ventricle patients.
        • Full-Text
        • PDF