Echocardiography for assessment of regional and global right ventricular systolic function in adults with repaired tetralogy of Fallot

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Abstract

Background

The right ventricular (RV) systolic function is important for decision making in adults with repaired tetralogy of Fallot (rTOF). Our aim was to assess regional RV systolic function and its impact on global RV systolic function by echocardiography.

Methods

In 101 adults with rTOF, regional RV systolic function on echocardiography was compared to 50 individuals with structurally normal hearts. In patients with rTOF, the impact of echocardiographic measures of regional RV systolic function on global RV-ejection fraction as measured by cardiac magnetic resonance imaging (CMR-RVEF) was determined.

Results

Compared to normals, patients with rTOF had impaired systolic function of the RV outflow tract. Patients with rTOF and normal CMR-RVEF compensate this loss of RV outflow tract function with increased contractions of the RV-body, measured as fractional area change on short axis (30 ± 12% versus 19 ± 7%, p < 0.0001) and on 4-chamber views (42 ± 7% versus 38 ± 8%, p = 0.06). In contrast, patients with rTOF and abnormal global CMR-RVEF showed significantly lower systolic function of the RV-body compared to normal controls (fractional area change on 4-chamber view: 31 ± 6% versus 38 ± 8%, p < 0.0001). A simple regression model, incorporating fractional shortening of RV outflow tract and fractional area change on 4-chamber view allows accurate echocardiographic estimation of the CMR-derived RVEF.

Conclusions

Patients with repaired tetralogy of Fallot have markedly different regional systolic RV-function compared to normals, even when the global RV systolic function is preserved. The systolic function of the RV outflow tract and of the RV body are both important determinants of global systolic RV function in these patients. Their prognostic significance needs to be determined.

Section snippets

Study subjects

From our clinic database we identified 101 consecutive adult subjects late after TOF-repair who had both a CMR and an echocardiogram less than 6 months apart (mean time between CMR and echocardiography was 0.7 ± 2.3 months). As a control population for echocardiographic measurements, 50 individuals with structurally normal hearts, referred for exclusion of a PFO were identified. The study was approved by the institutional ethics committee.

Echocardiograms

All transthoracic echocardiograms at our institution are

Study population

The mean age in the control group (50% males) was 38 ± 10 years and the mean age of patients with rTOF (60% males) was 33 ± 12 years (p = 0.05). A comparison of baseline characteristics of patients with rTOF randomly assigned to the derivation and the validation group is given in Table 1. There were no significant differences in any of the baseline characteristics between the two groups.

Acoustic window quality on echocardiography was judged good in 6%, fair in 86% and poor in 8%. No studies were

Discussion

In this study of patients late after TOF repair, echocardiography demonstrated significant differences in the regional systolic RV function as compared to individuals with structurally normal hearts. Patients with rTOF have significantly impaired systolic function of the RVOT. In contrast to rTOF-patients with abnormal CMR-RVEF, patients with rTOF and preserved global systolic RV-function compensate for this loss of RVOT function by the increased contraction of the RV-body.

Longitudinal

Limitations

Although all echocardiographic images at our institution are obtained according to a defined protocol, analysis of images was retrospective. For individuals in the control group with structurally normal hearts we assumed normal RV systolic function but CMR-data was not available. On the other hand, the regional systolic RV function was not available on CMR. Echocardiographic measurements of TAPSE were not made on M-mode images as originally proposed [30]. In patients with severely dilated RVs,

Conclusions

Patients with repaired tetralogy of Fallot have a markedly different pattern of regional systolic right ventricular function compared to individuals with structurally normal hearts. Radial contraction of the RVOT is impaired in most patients but those with preserved global systolic right ventricular function can compensate this loss of function with increased contractions of the body of the right ventricle. A quantitative echocardiographic model incorporating measures of systolic function of

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [31].

Conflicts of interest: None.

Relationship to industry: None.

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