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

Published:February 16, 2021DOI:



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


      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).


      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).


      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)
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      • Commentary: Maybe it is better to be a lefty
        The Journal of Thoracic and Cardiovascular SurgeryVol. 162Issue 6
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          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.
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