Structured Abstract
Objective
: We sought to couple current cardiac magnetic resonance (CMR) thresholds of right
ventricular (RV) size and function with longitudinal trajectories of RV recovery,
after pulmonary valve replacement (PVR). We aimed to identify optimal timing of PVR
and couple CMR-based metrics with contemporaneous echocardiographic metrics.
Methods
: From 6/2002 to 1/2019, 174 patients with severe pulmonary regurgitation and peak
RV outflow tract gradient <30 mmHg underwent PVR at Cleveland Clinic. Mean age was
35±16 years and 60 (34%) had concomitant tricuspid valve surgery. RV end diastolic
area index (RVEDAi) and function metrics were measured by offline image review on
preoperative and 794 postoperative echocardiograms. Contemporaneous RV end diastolic
volume index (RVEDVi) was assessed on CMR and correlated to RVEDAi. Multiphase nonlinear
mixed-effects models were used to analyze the longitudinal change in RV size and function
after PVR.
Results
: RVEDAi was correlated with RVEDVi (P<.0001, r=.59). RVEDAi decreased slowly over 10 years following PVR. An inflection
point at 24 cm2/m2 was noted at 1 year post-PVR and was associated with failure of RV reverse remodelling
and RVEDVi ≥ 150 ml/m2. Compared to patients with preoperative RVEDVi ≥ 150 mL/m2, patients with RVEDVi < 150 mL/m2 had accelerated recovery of longitudinal trajectories of RV size and function metrics
on echocardiograms.
Conclusion
: Reverse remodeling of RV following PVR is an ongoing process. Current accepted threshold
values for PVR are associated with greatest RV recovery, suggesting that earlier PVR
is warranted. Echocardiography can potentially be utilized in lieu of CMR for surveillance
and interventional triage.
Graphical abstract
Graphical Abstract
Keywords
Abbreviations:
CMR (Cardiac magnetic resonance), FAC (Fractional area change), MPI (Myocardial performance index), PVR (Pulmonary valve replacement), RV (Right ventricular), RVEDAi (Right ventricular end diastolic area index), RVEDVi (Right ventricular end diastolic volume index), RVOT (Right ventricular outflow tract), TAPSE (Tricuspid annular plane systolic excursion), TV (Tricuspid valve)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 accessOne-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 Seminars in Thoracic and Cardiovascular SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Indications for pulmonary valve replacement in repaired tetralogy of Fallot: the quest continues.Circulation. 2013; 128: 1855-1857
- Indications and timing of pulmonary valve replacement after tetralogy of Fallot repair.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006; : 11-22
- A propensity score-adjusted analysis of clinical outcomes after pulmonary valve replacement in tetralogy of Fallot.Heart. 2018; 104: 738-744
- Variable importance in binary regression trees and forests.Electron J Statist. 2007; 1: 519-537
- A multiphase non-linear mixed effects model: an application to spirometry after lung transplantation.Stat Methods Med Res. 2017; 26: 21-42
- Optimal timing for pulmonary valve replacement in asymptomatic patients after tetralogy of Fallot repair using cardiac magnetic resonance imaging.Kardiol Pol. 2018; 76: 1271-1273
- Meta-analysis of pulmonary valve replacement after operative repair of tetralogy of Fallot.Am J Cardiol. 2010; 106: 552-557
- Timing of pulmonary valve replacement: How much can the right ventricle dilate before it looses its remodeling potential?.Pediatr Cardiol. 2016; 37: 601-605
- Optimal timing for pulmonary valve replacement in adults after tetralogy of Fallot repair.Am J Cardiol. 2005; 95: 779-782
- Repaired tetralogy of Fallot: the roles of cardiovascular magnetic resonance in evaluating pathophysiology and for pulmonary valve replacement decision support.J Cardiovasc Magn Reson. 2011; 13: 9
- Can simple echocardiographic measures reduce the number of cardiac magnetic resonance imaging studies to diagnose right ventricular enlargement in congenital heart disease?.J Am Soc Echocardiogr. 2012; 25: 518-523
- Right Ventricular Fibrosis.Circulation. 2019 Jan 8; 139 (PMID: 30615500): 269-285https://doi.org/10.1161/CIRCULATIONAHA.118.035326
- Echocardiography for assessment of right ventricular volumes revisited: a cardiac magnetic resonance comparison study in adults with repaired tetralogy of Fallot.J Am Soc Echocardiogr. 2010; 23: 905-911
- Pulmonary valve replacement after operative repair of tetralogy of Fallot: meta-analysis and meta-regression of 3,118 patients from 48 studies.J Am Coll Cardiol. 2013; 62: 2227-2243
- Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance.Circulation. 2007; 116: 545-551
- Short-axis diastolic ventricular area ratio as a new index in screening patients with repaired tetralogy of Fallot.Pediatr Cardiol. 2018; 39: 1373-1377
- Tricuspid valve intervention at the time of pulmonary valve replacement in adults with congenital heart disease: a systematic review and meta-analysis.J Am Heart Assoc. 2021; 10e022909https://doi.org/10.1161/JAHA.121.022909
Article info
Publication history
Publication stage
In Press Journal Pre-ProofFootnotes
Read at the AATS 102nd Annual Meeting, May 14-17, 2022, Boston, MA
Presented at the 102nd Annual Meeting of the American Association of Thoracic Surgery, Boston MA
Author disclosures: Dr. Karamlou discloses a consulting relationship with Edwards Lifesciences. The remaining authors have no disclosures.
Funding: None
IRB: #12-687 approved on 07/09/2012 with patient consent waived
Identification
Copyright
© 2023 Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Commentary: Imaging Surveillance of Pulmonary Regurgitation: Is Echo Good Enough?Seminars in Thoracic and Cardiovascular Surgery
- PreviewAs congenital heart disease patients continue to live longer, the goal moves from simply survival to adulthood, to being physically active as an adult doing the activities they love. Advances in medical and surgical management have enabled such a paradigm shift, and for patients with tetralogy of Fallot, excellent late survival and good quality of life is expected. However, good quality of life for these patients often involves pulmonary valve replacement (PVR) at some point down the road. Part of this refinement in care has been optimizing timing PVR in patients who have previously undergone complete repair.
- Full-Text
- Preview
