End‐Diastolic Forward Flow and Restrictive Physiology in Repaired Tetralogy of Fallot: A Systematic Review and Meta‐Analysis

Abstract

Background Pulmonary arterial end‐diastolic forward flow (EDFF) following repaired tetralogy of Fallot has been thought to represent right ventricular (RV) restrictive physiology, but is not fully understood. This systematic review and meta‐analysis sought to clarify its physiological and clinical correlates, and to define a framework for understanding EDFF and RV restrictive physiology. Methods and Results PubMed/MEDLINE, Embase, Scopus, and reference lists of relevant articles were searched for observational studies published before March 2021. Random‐effects meta‐analysis was performed to identify factors associated with EDFF. Forty‐two individual studies published between 1995 and 2021, including a total of 2651 participants (1132 with EDFF; 1519 with no EDFF), met eligibility criteria. The pooled estimated prevalence of EDFF among patients with repaired tetralogy of Fallot was 46.5% (95% CI, 41.6%–51.3%). Among patients with EDFF, the use of a transannular patch was significantly more common, and their stay in the intensive care unit was longer. EDFF was associated with greater RV indexed volumes and mass, as well as smaller E‐wave velocity at the tricuspid valve. Finally, pulmonary regurgitation fraction was greater in patients with EDFF, and moderate to severe pulmonary regurgitation was more common in this population. Conclusions EDFF is associated with dilated, hypertrophied RVs and longstanding pulmonary regurgitation. Although several studies have defined RV restrictive physiology as the presence of EDFF, our study found no clear indicators of poor RV compliance in patients with EDFF, suggesting that EDFF may have multiple causes and might not be the precise equivalent of RV restrictive physiology.

Association of cardiovascular magnetic resonance diastolic indices with arrhythmia in repaired Tetralogy of Fallot

“…Additionally, RV diastolic dysfunction was not measured in this study due to the complexity of RV geometry, filling, and tricuspid valve inflow. A recent meta-analysis demonstrated that other markers of RV diastolic dysfunction, including end-diastolic forward flow, may not be specific for restrictive RV physiology, demonstrating the complexity associated with CMR assessment of RV diastolic dysfunction [34]. Some studies suggest that more accurate assessments of RV diastology may be achieved with four-dimensional CMR [33].…”

End-diastolic forward flow in repaired tetralogy of Fallot: Mid-term outcomes from a single center

“…The prevalence of EDFF among rTOF patients was 52, 43.3, and 49.5% at perioperative period, the first follow-up with a median time of 3 months and the last follow-up with a median time of 31 months, respectively. A recent systematic review and meta-analysis demostrated that the prevalence of EDFF among patients with repaired TOF was 46.5% (95% CI, 41.6–51.3%), which was closed to the result of our center ( 9 ). In our cohort, patients with PV dilatation had a lower incidence of EDFF than surgically corrected patients, and patients with TAP repair were more likely to appear EDFF after surgery.…”

“…End-diastolic forward flow (EDFF) in the main pulmonary artery, resulting from diastolic RV stiffness ( 4 ), is regarded as a manifestation of RV restrictive physiology in many studies ( 2 , 7 , 8 ). More and more attention has been paid to this phenomenon in rTOF patients ( 8 , 9 ), whereas the risk factors of EDFF are not clear, which mostly focus on preoperative physiological state and surgical procedures, such as transannular patch (TAP) ( 6 ). Studies of the association between TAP and EDFF have yielded divergent results.…”

Multimodality Imaging Assessment of Tetralogy of Fallot: From Diagnosis to Long-Term Follow-Up

“…Patients with repaired TOF tend to require multiple PV replacements (PVR), and CMR plays a pivotal role in selecting the correct replacement timing [44,48,49].…”