Additional mechanism for left ventricular dysfunction: chronic pulmonary regurgitation decreases left ventricular preload in patients with tetralogy of Fallot

Ylitalo, Pekka; Jokinen, Eero; Lauerma, Kirsi; Holmström, Miia; Pitkänen‐Argillander, Olli

doi:10.1017/s1047951117001457

Cited by 5 publications

(4 citation statements)

References 27 publications

(51 reference statements)

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“…Cardiac function is not only dependent on the atrioventricular coupling but also on the interventricular interaction consisting of loading conditions and a common septum. Severe PR has been shown to cause decreased filling of the left atrium (23,36). The current results support that patients with PR have decreased filling mainly during systole compared with controls.…”

Section: Discussionsupporting

confidence: 82%

Changes in left and right ventricular longitudinal function after pulmonary valve replacement in patients with Tetralogy of Fallot

Sjöberg

Ostenfeld

Hedström

et al. 2020

American Journal of Physiology-Heart and Circulatory Physiology

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Timing and indication for pulmonary valve replacement (PVR) in patients with repaired Tetralogy of Fallot (rToF) and pulmonary regurgitation (PR) are uncertain. To improve understanding of pumping mechanics, we investigated atrioventricular coupling before and after surgical PVR. Cardiovascular magnetic resonance was performed in patients ( n = 12) with rToF and PR > 35% before and after PVR and in healthy controls ( n = 15). Atrioventricular plane displacement (AVPD), global longitudinal peak systolic strain (GLS), atrial and ventricular volumes, and caval blood flows were analyzed. Right ventricular (RV) AVPD and RV free wall GLS were lower in patients before PVR compared with controls ( P < 0.0001; P < 0.01) and decreased after PVR ( P < 0.0001 for both). Left ventricular AVPD was lower in patients before PVR compared with controls ( P < 0.05) and decreased after PVR ( P < 0.01). Left ventricular GLS did not differ between patients and controls ( P > 0.05). Right atrial reservoir volume and RV stroke volume generated by AVPD correlated in controls ( r = 0.93; P < 0.0001) and patients before PVR ( r = 0.88; P < 0.001) but not after PVR. In conclusion, there is a clear atrioventricular coupling in patients before PVR that is lost after PVR, possibly because of loss of pericardial integrity. Impaired atrioventricular coupling complicates assessment of ventricular function after surgery using measurements of longitudinal function. Changes in atrioventricular coupling seen in patients with rToF may be energetically unfavorable, and long-term effects of surgery on atrioventricular coupling is therefore of interest. Also, AVPD and GLS cannot be used interchangeably to assess longitudinal function in rToF. NEW & NOTEWORTHY There is a clear atrioventricular coupling in patients with Tetralogy of Fallot (ToF) and pulmonary regurgitation before surgical pulmonary valve replacement (PVR) that is lost after operation, possibly because of loss of pericardial integrity. The impaired atrioventricular coupling complicates assessment of ventricular function after surgery when using measurements of longitudinal function. Left ventricular atrioventricular plane displacement (AVPD) found differences between patients and controls and changes after PVR that longitudinal strain could not detect. This indicates that AVPD and strain cannot be used interchangeably to assess longitudinal function in repaired ToF.

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Section: Discussionsupporting

confidence: 82%

Changes in left and right ventricular longitudinal function after pulmonary valve replacement in patients with Tetralogy of Fallot

Sjöberg

Ostenfeld

Hedström

et al. 2020

American Journal of Physiology-Heart and Circulatory Physiology

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“…LV longitudinal strain in diastole returned to zero faster in patients with TOF than in healthy subjects. It has been previously documented that left ventricular preload is decreased in TOF patients and is caused by decreased transpulmonary flow due to pulmonary regurgitation [17]. It is possible that the diastolic phase of our patients was affected by the smaller stroke volume.…”

Section: Discussionmentioning

confidence: 79%

“…These conditions may be due to the impact of electromechanical asynchrony after patching of the ventricular septal defect, shared myocardial structures, or septal deviation. In addition, recent findings of altered LV preloading due to impaired transpulmonary flow may be important for the long-term postoperative health [13][14][15][16][17].…”

Section: Introductionmentioning

confidence: 99%

Severe pulmonary regurgitation in adolescents with tetralogy of Fallot leads to increased longitudinal strain

Ylitalo

Lehmonen

Lauerma

et al. 2019

Magn Reson Mater Phy

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Objectives Postoperative patients with tetralogy of Fallot (TOF) are often compromised by chronic pulmonary regurgitation and chronic right ventricular volume load. We sought to determine whether pulmonary regurgitation (PR) would affect right and left ventricle (RV and LV) strain. Materials and methods This cross-sectional analysis included 40 patients who had TOF with surgical repair, with an average follow-up period of 11.8 ± 3.0 years. Altogether, 44 healthy volunteers with similar age and gender distribution were recruited. A cardiovascular magnetic resonance imaging study with feature tracking analysis was performed on all patients and controls. Results RV peak longitudinal strain was increased in TOF patients with PR > 30 ml/m 2 when compared to those with PR < 30 ml/m 2 (− 22.5% ± 2.7% vs − 19.7% ± 3.5%, p = 0.018) and controls (p = 0.007). PR volume correlated with peak RV longitudinal strain (R = − 0.37, p = 0.030) and peak RV longitudinal strain rate (systolic: R = 0.37, p = 0.03; diastolic: R = 0.39, p = 0.021). The peak RV circumferential strain, from base to apex, increased more than in healthy controls (apexbase difference 7.6% ± 4.2% vs 3.3% ± 2.4%, p < 0.0001). Conclusions Pediatric patients with TOF and a severe pulmonary regurgitation show an enhanced longitudinal strain when compared to patients with milder regurgitation or to control subjects. In addition, mean RV circumferential strain of the patients is significantly enhanced compared to healthy individuals.

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“…These results are in line with other studies ( Teo et al, 2008 ; Yoshiba et al, 2021 ). The reason for lower left ventricular end-diastolic volume and stroke volume in patients with rToF compared to controls might be explained by reduced transpulmonary flow caused by the pulmonary regurgitation leading to low left ventricular filling ( Kopic et al, 2017 ; Ylitalo et al, 2018 ). The LV volumes were however within normal range and the control groups ventricular volumes were towards the upper limit, which might exaggerate the difference.…”

Section: Discussionmentioning

confidence: 99%

Patients with volume-loaded right ventricle - quantification of left ventricular hemodynamic response to intervention measured by noninvasive pressure-volume loops

Sjöberg,

Stephensen,

Arheden

et al. 2023

Front. Physiol.

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Volume loading of the right ventricle (RV) in patients with atrial septal defect (ASD) and patients with repaired Tetralogy of Fallot (rToF) affects the pumping mechanics of the left ventricle (LV). Intervention of the lesion will relieve the RV volume load however quantifiable impact on exercise capacity, arrhytmias or death are limited. A possible explanation could be remaining effects on the function of the LV. The aim of this study was therefore to investigate if hemodynamics of the LV differs between patients with RV volume load due to ASD or rToF and healthy controls and if they change after intervention. Eighteen patients with ASD, 17 patients with rToF and 16 healthy controls underwent cardiac magnetic resonance imaging (CMR) and maximal exercise test with continuous gas analysis. Reexamination was performed 13 ± 2 months after closure of the ASD in 13 of the patients and 10 ± 4 months after pulmonary valve replacement (PVR) in 9 of the patients with rToF. Non-invasive PV-loops from CMR and brachial pressures were analyzed. Stroke work (SW) and potential energy (PE) increased after ASD closure but not in ToF patients after valve repair. Patients with ASD or rToF had higher contractility and arterial elastance than controls. No major effects were seen in LV energetics or in peak VO2 after ASD closure or PVR. Peak VO2 correlated positively with SW and PE in patients with ASD (r = 0.54, p < 0.05; r = 0.61, p < 0.01) and controls (r = 0.72, p < 0.01; r = 0.53, p < 0.05) to approximately the same degree as peak VO2 and end-diastolic volume (EDV) or end-systolic volume (ESV). In ToF patients there was no correlation between PV loop parameters and peak VO2 even if correlation was found between peak VO2 and EDV or ESV. In conclusion, the LV seems to adapt its pumping according to anatomic circumstances without losing efficiency, however there are indications of persistent vascular dysfunction, expressed as high arterial elastance, which might have impact on exercise performance and prognosis. Future studies might elucidate if the duration of RV volume load and decreased LV filling have any impact on the ability of the vascular function to normalize after ASD closure or PVR.

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Additional mechanism for left ventricular dysfunction: chronic pulmonary regurgitation decreases left ventricular preload in patients with tetralogy of Fallot

Abstract: In patients with tetralogy of Fallot, severe pulmonary regurgitation has a significant effect on volume flow through the left atrium. Reduction in left ventricular preload volume may be an additional factor contributing to left ventricular dysfunction.

Cited by 5 publications

References 27 publications

Changes in left and right ventricular longitudinal function after pulmonary valve replacement in patients with Tetralogy of Fallot

Changes in left and right ventricular longitudinal function after pulmonary valve replacement in patients with Tetralogy of Fallot

Severe pulmonary regurgitation in adolescents with tetralogy of Fallot leads to increased longitudinal strain

Patients with volume-loaded right ventricle - quantification of left ventricular hemodynamic response to intervention measured by noninvasive pressure-volume loops

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