Artery Systolic Pressure Ratio Research Articles

Outcome of Patients With Cardiogenic Shock and Previous Right Ventricular Impairment Represented by Decreased Tricuspid Annular Plane Systolic Excursion and Tricuspid Annular Plane Systolic Excursion to Pulmonary Artery Systolic Pressure Ratio

This study investigates the prognostic impact of known decreased ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP) and TAPSE in patients with cardiogenic shock (CS). In patients with pulmonary artery hypertension and in critically ill patients, decreased TAPSE and TAPSE/PASP ratio are known to be negative predictors. However, studies regarding the prognostic impact in patients with CS are limited. Consecutive patients with CS from June 2019 to May 2021 treated at a single center were included. Medical history including echocardiographic parameters such as TAPSE and PASP was documented for each patient. The primary endpoint was all-cause mortality at 30 days. Statistical analyses included univariable ttest, Spearman's correlation, C-statistics, Kaplan-Meier analyses, and Cox proportional regression analyses. A total of 90 patients with CS and measurement of TAPSE and TAPSE/PASP ratio were included. TAPSE and TAPSE/PASP ratio measured several months before intensive care unit admission were both able to predict 30-day survival in CS patients, and were both lower in 30-day nonsurvivors. TAPSE/PASP ratio <0.4mm/mmHg (log-rank p=0.006) and TAPSE <18mm (log-rank p=0.004) were associated with increased risk of 30-day all-cause mortality. After multivariable adjustment, TAPSE/PASP ratio <0.4mm/mmHg was not able to predict 30-day all-cause mortality, whereas TAPSE <18mm was still significantly associated with the primary endpoint (hazard ratio 2.336, confidence interval 1.067 to 5.115, p=0.034). In consecutive patients presenting with CS, compared to TAPSE alone, previously determined TAPSE/PASP ratio did not improve risk prediction for 30-day all-cause mortality.

Tricuspid Annular Plane Systolic Excursion/Pulmonary Arterial Systolic Pressure Ratio as a Predictor of Mortality in Heart Failure Patients

Aims: We aimed to investigate the prognostic value of the tricuspid annular plane systolic excursion (TAPSE)/ pulmonary arterial systolic pressure (PASP) ratio in Moroccan patients with heart Failure (HF). &#x0D; Study Design: A retrospective study was conducted in The Cardiology Department of Ibn Rochd Hospital of Casablanca in Morocco. The study was conducted in the period between March 2012 to March 2016 with a follow-up until December 2022.&#x0D; Methods: data were evaluated from the HF register patients and their relatives were contacted by phone. Patients with reduced LVEF were included, patients with pulmonary embolism, and patients with HFpEF were excluded. The endpoint of the study was mortality.&#x0D; Results: 128 patients were enrolled Over an average follow-up of 58 months. 51(41.4%) patients died at the end of the follow-up, the median value of left ventricular ejection fraction was 35.2 ± 2.2%. Patients were stratified according to the TAPSE/PASP ratio (low &lt;0.32 mm/mmHg; high: &gt;0.32 mm/mmHg). Kaplan-Meier survival analysis showed that ten-year all-cause mortality was significantly higher in patients with TAPSE/PASP ≤0.32 mm/mmHg than in patients with TAPSE/PASP &gt; 0.32 mm/mmHg (log-rank 7.8, p =0.008) Cox regression analysis revealed that lower LVEF (p= 0.04), and a ratio of TAPSE\PAPS &lt;0.32 (p=0.02) were associated to an increase in all-cause mortality. &#x0D; Conclusion: Correlating right ventricular function to loading conditions may be more accurate in assessing its real contractility and predicting patients’ outcomes. Our study showed that TAPSE/PASP appears as a novel prognostic predictor in patients with Heart failure.

Literature Review-Transthoracic Echocardiography, Computed Tomography Angiography, and Their Value in Clinical Decision Making and Outcome Predictions in Patients with COVID-19 Associated Cardiovascular Complications.

The sudden outbreak of the COVID-19 pandemic posed a great threat to the world's healthcare systems. It resulted in the development of new methods and algorithms for the diagnosis and treatment of both COVID-19 and its complications. Diagnostic imaging played a crucial role in both cases. Among the most widely used examinations are transthoracic echocardiography (TTE) and computed tomography angiography (CTA). Cardiovascular complications in COVID-19 are frequently associated with a severe inflammatory response, which results in acute respiratory failure, further leading to severe complications of the cardiovascular system. Our review aims to discuss the value of TTE and CTA in clinical decision making and outcome prediction in patients with COVID-19-associated cardiovascular complications. Our review revealed the high clinical value of various TTE findings and their association with mortality and the prediction of patients' clinical outcomes, especially when used with other laboratory parameters. The strongest association between increased mortality and findings in TTE was observed for tachycardia and decreased left ventricular ejection fraction (odds ratio (OR) 24.06) and tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio (TAPSE/PASP ratio) < 0.31 mm/mmHg (OR 17.80). CTA is a valuable tool in diagnosing COVID-19-associated pulmonary embolism, but its association with mortality and its predictive role should always be combined with laboratory findings and patients' medical history. D-dimers > 3000 ng/mL were found as the strongest predictors of pulmonary embolism (PE) (OR 7.494). Our review indicates the necessity for an active search for cardiovascular complications in patients with severe COVID-19, as they are linked with an increased probability of fatal outcomes.

Short term Prognostic value of tricuspid annular plane systolic excursion / pulmonary arterial systolic pressure ratio in patients with COVID-19 ARDS

Short term Prognostic value of tricuspid annular plane systolic excursion / pulmonary arterial systolic pressure ratio in patients with COVID-19 ARDS

Tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio as a predictor of in-hospital mortality for acute heart failure

BackgroundRight ventricular (RV) function is an important prognostic factor in heart failure. Patients with impaired right ventricular function have a poorer prognosis. The ratio between a tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) is a simple non-invasive parameter that has shown a good correlation with invasively estimated right ventricle (RV)-pulmonary artery (PA) coupling. The current study aimed to determine the value of the non-invasive evaluation of RV-PA coupling using the TAPSE/PASP ratio in predicting in-hospital mortality in patients with acute heart failure.MethodsWe included 200 patients with (heart failure and reduced ejection fraction) HFrEF presented by acute heart failure. Echocardiographic evaluation for left ventricle systolic and diastolic function was performed at the time of admission. RV functions were evaluated by calculating the following (TAPSE, PSAP, TAPSE/PASP ratio). Data were analyzed to find the predictors of in-hospital mortality.ResultsThe study cohort included two hundred consecutive patients who were hospitalized for a diagnosis of acute decompensation of chronic heart failure. The in-hospital mortality rate was 12%. TAPSE/PASP was an independent predictor for in-hospital mortality (odd ratio = 3.470; 95% confidence interval, 1.240–9.705, p-value = 0.018) and (odd ratio = 18.813; 95% confidence interval, 1.974–179.275, p-value = 0.011) in univariate and multivariable logistic regression analyses respectively. In ROC curve analysis, TAPSE/PASP with a cut-off value < 0.4 mm/mmHg had a sensitivity of 79.17, a specificity of 47.73, and an area under ROC curve = 0.666 for predicting in-hospital mortality.ConclusionsThe non-invasive TAPSE/PASP ratio could be an independent predictor of mortality in HErEF patients presenting with acute heart failure.

Right ventricular pressure-volume loop shape and systolic pressure change in pulmonary hypertension.

Right ventricular (RV) function determines outcome in pulmonary arterial hypertension (PAH). RV pressure-volume loops, the gold standard for measuring RV function, are difficult to analyze. Our aim was to investigate whether simple assessments of RV pressure-volume loop morphology and RV systolic pressure differential reflect PAH severity and RV function. We analyzed multibeat RV pressure-volume loops (obtained by conductance catheterization with preload reduction) in 77 patients with PAH and 15 patients without pulmonary hypertension in two centers. Patients were categorized according to their pressure-volume loop shape (triangular, quadratic, trapezoid, or notched). RV systolic pressure differential was defined as end-systolic minus beginning-systolic pressure (ESP - BSP), augmentation index as ESP - BSP/pulse pressure, pulmonary arterial capacitance (PAC) as stroke volume/pulse pressure, and RV-arterial coupling as end-systolic/arterial elastance (Ees/Ea). Trapezoid and notched pressure-volume loops were associated with the highest afterload (Ea), augmentation index, pulmonary vascular resistance (PVR), mean pulmonary arterial pressure, stroke work, B-type natriuretic peptide, and the lowest Ees/Ea and PAC. Multivariate linear regression identified Ea, PVR, and stroke work as the main determinants of ESP - BSP. ESP - BSP also significantly correlated with multibeat Ees/Ea (Spearman's ρ: -0.518, P < 0.001). A separate retrospective analysis of 113 patients with PAH showed that ESP - BSP obtained by routine right heart catheterization significantly correlated with a noninvasive surrogate of RV-arterial coupling (tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio; ρ: -0.376, P < 0.001). In conclusion, pressure-volume loop shape and RV systolic pressure differential predominately depend on afterload and PAH severity and reflect RV-arterial coupling in PAH.

Donor-recipient predicted heart mass ratio and right ventricular-pulmonary arterial coupling in heart transplant.

Right ventricular-pulmonary arterial (RV-PA) coupling interactions are largely unexplored in heart transplant patients. The outcome of this study was RV-PA coupling at 7 and 30 days after heart transplant and its association with donor-recipient size matching. Clinical, echocardiographic and haemodynamic data from a retrospective cohort of heart transplant recipients and respective donors were reviewed. Coupling between RV-PA was examined by assessing the RV fractional area change and pulmonary artery systolic pressure ratio. Donor-recipient size matching was assessed by the predicted heart mass (PHM) ratio, and groups with a PHM ratio <1 and ≥1 were compared. Forty-four heart transplant recipients were included in this study (50 years, 57% male sex). Postoperative RV-PA coupling improved from 7 to 30 days (RV fractional area change/pulmonary artery systolic pressure 0.9 ± 0.3 vs 1.2 ± 0.3; P < 0.001). A positive association was found between an adequate PHM ratio and improvement of RV fractional area change/pulmonary artery systolic pressure at 30 days, independent of graft ischaemic time and pre-existent pulmonary hypertension (B coefficient 0.54; 95% confidence interval 0.11-0.97; P = 0.016; adjusted R2 = 0.24). These findings highlight the role of PHM as a metric to help donor selection and suggest its impact in RV-PA coupling interactions post-heart transplant.

Prognostic Importance of Right Ventricular-Vascular Uncoupling in Acute Decompensated Heart Failure With Preserved Ejection Fraction.

Recent accumulating evidence reveals that the right ventricular (RV)-pulmonary artery (PA) uncoupling is associated with poor outcome in patients with heart failure (HF), RV dysfunction, and pulmonary hypertension. However, the prognostic utility of RV-PA uncoupling in HF with preserved ejection fraction (HFpEF) remains elusive. In this study, we aim to investigate the associations of RV-PA uncoupling with outcomes of HFpEF inpatients. We prospectively studied 655 patients, registered in PURSUIT-HFpEF (The Prospective Multicenter Obervational Study of Patients with Heart Failure with Preserved Ejection Fraction), a multicenter observational study of Japanese HFpEF inpatients. We assigned registered patients based on the determined value of tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ratio that can predict primary outcome as an indicator of RV-PA uncoupling. Univariable Cox regression testing revealed that RV-PA uncoupling was associated with the primary endpoint of all-cause death, HF rehospitalization, and cerebrovascular events (hazard ratio [HR] 1.77 [95% CI, 1.34-2.32], P<0.0001) and the secondary endpoints of all-cause death and HF rehospitalization (HR 2.75 [95% CI, 1.77-4.33], P<0.0001, HR 1.63 [95% CI, 1.18-2.26], P=0.0036, respectively). Multivariable analysis also showed that RV-PA uncoupling was significantly associated with primary endpoint and all-cause death independent of age, sex, atrial fibrillation, renal dysfunction, elevated E/e', and elevated NT-proBNP (N-terminal pro-B-type natriuretic peptide) (HR 1.38 [95% CI, 1.01-1.88], P=0.0413, HR 1.85 [95% CI, 1.14-3.01], P=0.0129, respectively). Prospective study of a hospitalized cohort revealed that RV-PA uncoupling was independently associated with adverse outcomes in acute decompensated patients with HFpEF. Registration: URL: https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000024414. Unique identifier: UMIN000021831.

Prognostic implications of tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure ratio in septic shock patients

BackgroundTo explore the association between the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP), and long- and short-term outcomes in mechanically ventilated septic shock patients.MethodsSeptic shock patients admitted to the intensive care unit (ICU) were screened for enrollment. Echocardiographic parameters including TAPSE and tricuspid regurgitation velocity, haemodynamic and respiratory parameters, and prognostic data were obtained.ResultsOne hundred eighteen subjects were enrolled in this study, among whom 75 survived and 43 died at the one-year follow-up. ROC curve analysis revealed that the TAPSE/PASP ratio was able to assess one-year all-cause mortality with an area under the curve of 0.817 (95% CI: 0.739–0.896, p < 0.001) and the optimal cutoff value was 0.50 mm/mmHg. Kaplan-Meier survival analysis showed that one-year all-cause mortality was significantly higher in patients with TAPSE/PASP ≤0.5 mm/mmHg than in patients with TAPSE/PASP > 0.5 mm/mmHg (log-rank 32.934, p < 0.001). According to the Cox regression survival analyses, the TAPSE/PASP ratio was independently associated with one-year all-cause mortality (HR 0.007, 95% CI:0.000–0.162, p = 0.002) and ICU mortality (HR 0.027, 95% CI:0.001–0.530, p = 0.017). According to the multivariable analysis, the TAPSE/PASP ratio was an independent variable associated with mechanical ventilation (MV) duration (standard coefficient − 0.240, p = 0.010).ConclusionThe TAPSE/PASP ratio demonstrated prognostic value for one-year all-cause mortality, ICU mortality and MV duration in mechanically ventilated septic shock patients.

Right Ventricular Function Coupling to the Pulmonary Circulation Predicts Exercise Tolerance in Patients with Heart Failure and Reduced Ejection Fraction. Insight from the Evaluation of Resynchronization Therapy for Heart Failure (EARTH) Trial

Exercise tolerance has important prognostic value in patients with heart failure and reduced ejection fraction (HFrEF). The relationship between right ventricular function and its coupling to pulmonary circulation (RV-PA) and cardiopulmonary exercise tests (CPET) is not fully understood. We aimed to evaluate the value of RV echocardiographic parameters, including RV-PA, to predict exercise tolerance in HFrEF patients. We performed a sub-analysis of EARTH, which enrolled HFrEF patients undergoing defibrillator implantation. At baseline, an echocardiogram and various CPET [peak VO2; minute ventilation/carbon dioxide production slope (VE/VCO2); 6-minute walk distance (6MWD) and submaximal exercise duration (SED)] were performed. The primary outcome was the correlation of RV-PA (using TAPSE/sPAP, tricuspid annular plane systolic excursion on pulmonary artery systolic pressure ratio (T/P)) with peak VO2. Secondary outcomes include correlation between various RV parameters such as size [diameter at inlet and end-diastolic area in apical 4-chamber], RV function [TAPSE; right ventricular fractional area change (RV-FAC); RV myocardial performance index (RV-MPI)], sPAP and tricuspid regurgitation grade (TRG); and CPET variables. Univariate and multivariate linear regression models were used on patients for which both TAPSE and sPAP were available. 205 patients were enrolled in EARTH, with 100 having data on both TAPSE and sPAP (Men: 70.0%; NYHA class II: 55.0%; mean LVEF 26.5±7.8%). T/P was the only parameter found to be predictive of peak VO2 (β=6.8, p<0.01), together with BMI for 6MWD (β=72.4, p=0.04). ROC analysis for T/P value predictive of peak VO2 ≤14mL/kg/min showed sensitivity and specificity of 0.63 and 0.62 respectively, and area under the curve (AUC) of 0.66 (p<0.01) for an optimal threshold ≤0.45. T/P and RV-MPI were both predictors (β=-18.0, p<0.01; β=18.5, p<0.01 respectively) of VE/VCO2 slope, while only TRG and BMI predicted SED (β=-3.2, p=0.03). In HFrEF patients, RV-PA coupling (using TAPSE/sPAP) is a powerful predictor of maximal and submaximal exercise capacity and has a greater predictive value than the usual parameters including age, sex and LVEF.

RIGHT VENTRICULAR FUNCTION COUPLING TO THE PULMONARY CIRCULATION PREDICTS EXERCISE TOLERANCE IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION: INSIGHT FROM THE EVALUATION OF RESYNCHRONIZATION THERAPY FOR HEART FAILURE (EARTH) TRIAL

Purpose Exercise tolerance has important prognostic value in patients with heart failure and reduced ejection fraction (HFrEF). The relationship between right ventricular function and its coupling to pulmonary circulation (RV-PA) and cardiopulmonary exercise tests (CPET) is not fully understood. We aimed to evaluate the value of RV echocardiographic parameters, including RV-PA, to predict exercise tolerance in HFrEF patients. Methods We performed a sub-analysis of EARTH, which enrolled HFrEF patients undergoing defibrillator implantation. At baseline, an echocardiogram and various CPET [peak VO2; minute ventilation/carbon dioxide production slope (VE/VCO2); 6-minute walk distance (6MWD) and submaximal exercise duration (SED)] were performed. The primary outcome was the correlation of RV-PA (using TAPSE/sPAP, tricuspid annular plane systolic excursion on pulmonary artery systolic pressure ratio (T/P)) with peak VO2. Secondary outcomes include correlation between various RV parameters such as size [diameter at inlet and end-diastolic area in apical 4-chamber], RV function [TAPSE; right ventricular fractional area change (RV-FAC); RV myocardial performance index (RV-MPI)], sPAP and tricuspid regurgitation grade (TRG); and CPET variables. Univariate and multivariate linear regression models were used on patients for which both TAPSE and sPAP were available. Results 205 patients were enrolled in EARTH, with 100 having data on both TAPSE and sPAP (Men: 70.0%; NYHA class II: 55.0%; mean LVEF 26.5±7.8%). T/P was the only parameter found to be predictive of peak VO2 (β=6.8, p Conclusion In HFrEF patients, RV-PA coupling (using TAPSE/sPAP) is a powerful predictor of maximal and submaximal exercise capacity and has a greater predictive value than the usual parameters including age, sex and LVEF.

Right Ventricular Function and Sexual Function: Exploring Shadows in Male and Female Patients With Heart Failure

IntroductionSexual health plays an important role in heart failure (HF) patients, and the relationship between HF and sexual dysfunction is well established; however, the role of right ventricular function in sexual dysfunction has not been investigated sufficiently. AimTo investigate the potential association between right ventricular dysfunction and sexual dysfunction in both male and female patients with HF. MethodsPatients with a clinical diagnosis of HF were evaluated in a cross-sectional study. Patients from the whole spectrum of HF were included in the study, regardless of cause, duration, and classification of HF. Sexual function in men was evaluated with the International Index of Erectile Function and in women with the Female Sexual Functioning Index. Main Outcome MeasuresWe demonstrate that right ventricular dysfunction is associated with worse sexual function in both men and women. Results306 consecutive patients with HF participated in the study. Right ventricular systolic dysfunction ranged from 24.2–39.1% and right ventricular diastolic dysfunction from 16.1–83.1%, depending on the echocardiographic parameter that was assessed. Right ventricular systolic dysfunction assessed by tricuspid annular plane systolic excursion (TAPSE), TAPSE/pulmonary artery systolic pressure ratio, and right ventricular basal diameter was associated with a lower International Index of Erectile Function score (P = .031, P = .009, and P < .001, respectively). Multiple linear regression analysis revealed that erectile function was independently associated only with TAPSE/pulmonary artery systolic pressure ratio and tricuspid late tricuspid diastolic flow velocity wave (β = 32.84, P = .006; and β = −0.47, P = .026, respectively), whereas female sexual function was independently associated only with the early tricuspid diastolic flow velocity/late tricuspid diastolic flow velocity ratio (β= −0.47, P = .026). Clinical ImplicationsOur study demonstrates that right ventricular dysfunction in patients with HF reflects an impaired sexual function status. Physicians should be aware of this association and closely evaluate those patients for sexual dysfunction. Strengths & LimitationsWe innovatively assessed the correlation between right ventricular dysfunction and sexual function using validated questionnaires. The main limitation is the relatively small sample size. ConclusionsOur study provides some new insights into the relationship between sexual dysfunction and right ventricular systolic and diastolic dysfunction in HF patients, also suggesting potential interventions to improve sexual and right ventricular function and prognosis in this population.Koutsampasopoulos K, Vogiatzis I, Ziakas A, et al. Right Ventricular Function and Sexual Function: Exploring Shadows in Male and Female Patients With Heart Failure. J Sex Med 2019;16:1199–1211.

Right ventricular outflow tract velocity time integral-to-pulmonary artery systolic pressure ratio: a non-invasive metric of pulmonary arterial compliance differs across the spectrum of pulmonary hypertension.

Pulmonary arterial compliance (PAC), invasively assessed by the ratio of stroke volume to pulmonary arterial (PA) pulse pressure, is a sensitive marker of right ventricular (RV)-PA coupling that differs across the spectrum of pulmonary hypertension (PH) and is predictive of outcomes. We assessed whether the echocardiographically derived ratio of RV outflow tract velocity time integral to PA systolic pressure (RVOT-VTI/PASP) (a) correlates with invasive PAC, (b) discriminates heart failure with preserved ejection-associated PH (HFpEF-PH) from pulmonary arterial hypertension (PAH), and (c) is associated with functional capacity. We performed a retrospective cohort study of patients with PAH (n = 70) and HFpEF-PH (n = 86), which was further dichotomized by diastolic pressure gradient (DPG) into isolated post-capillary PH (DPG < 7 mmHg; Ipc-PH, n = 54), and combined post- and pre-capillary PH (DPG ≥ 7 mm Hg; Cpc-PH, n = 32). Of the 156 patients, 146 had measurable RVOT-VTI or PASP and were included in further analysis. RVOT-VTI/PASP correlated with invasive PAC overall (ρ = 0.61, P < 0.001) and for the PAH (ρ = 0.38, P = 0.002) and HFpEF-PH (ρ = 0.63, P < 0.001) groups individually. RVOT-VTI/PASP differed significantly across the PH spectrum (PAH: 0.13 [0.010–0.25] vs. Cpc-PH: 0.20 [0.12–0.25] vs. Ipc-PH: 0.35 [0.22–0.44]; P < 0.001), distinguished HFpEF-PH from PAH (AUC = 0.72, 95% CI = 0.63–0.81) and Cpc-PH from Ipc-PH (AUC = 0.78, 95% CI = 0.68–0.88), and remained independently predictive of 6-min walk distance after multivariate analysis (standardized β-coefficient = 27.7, 95% CI = 9.2–46.3; P = 0.004). Echocardiographic RVOT-VTI/PASP is a novel non-invasive metric of PAC that differs across the spectrum of PH. It distinguishes the degree of pre-capillary disease within HFpEF-PH and is predictive of functional capacity.

123 - Right Ventricular Outflow Tract Velocity Time Integral to Pulmonary Artery Systolic Pressure Ratio: A New Non-Invasive Metric of Pulmonary Arterial Compliance

123 - Right Ventricular Outflow Tract Velocity Time Integral to Pulmonary Artery Systolic Pressure Ratio: A New Non-Invasive Metric of Pulmonary Arterial Compliance

Balloon pulmonary valvoplasty: factors determining short- and long-term results

Balloon pulmonary valvoplasty was performed in 139 patients (age 2–44 years) with pulmonary valve seenosis. The right ventricular peak systolic pressure decreased from 137.1 ± 46.8 mmHg to 76 ± 51.3 mmHg ( P < 0.001) and the right ventricle to pulmonary artery peak systolic gradient decreased from 116.3 ± 49 mmHg to 54.4 ± 51.9 mmHg ( P < 0.001). There was no significant change in systemic artery systolic pressure. The right ventricular peak systolic pressure to systemic artery systolic pressure ratio decreased from 1.13 ± 0.41 to 0.63 ± 0.42 ( P < 0.001). Patients with incomplete immediate relief of obstruction (right ventricle to pulmonary artery peak systolic gradient > 35 mmHg) had higher pre-dilatation right ventricular peak systolic pressure (161.1 ± 45.3 mmHg vs. 93.9 ± 38.8 mmHg, P < 0.001) and higher right ventricular peak systolic pressure to systemic artery systolic pressure ratio (1.31 ± 0.42 vs 0.98 ± 0.33, P < 0.001) pre-dilatation and were older (17.2 ± 8.6 years vs. 12.8 ± 9.7 years, P < 0.01). The residual right ventricle to pulmonary artery peak systolic gradients in the majority of patients were infundibular, which regressed at follow up even in patients who did not receive long-term oral beta blockers. Follow up catheterisation in 79 patients after 13 ± 8.7 months showed a further fall in right ventricular peak systolic-pressure ( P < 0.001) and right ventricle-to-pulmonary artery peak systolic gradient ( P < 0.001). As assessed by follow up catheterisation data, 81% had no significant residual right ventricle-to-pulmonary artery peak systolic gradient while four patients showed significant increase in gradients compared to values obtained immediately after balloon pulmonary valvoplasty. A higher postdilatation right ventricular peak systolic pressure to systemic artery systolic pressure ratio was predictive of an unsatisfactory late result. Among patients with a dysplastic pulmonary valve only those with a mild degree of dysplasia improved. In conclusion balloon pulmonary valvoplasty is safe and provides long-term relief of obstruction in the majority of patients with pulmonary valve stenosis. Older patients with more severe stenosis are more likely to have residual infundibular gradients. Infundibular gradients regress at followup with or without beta blockers.

Repair of complete atrioventricular canal in infancy

AbstractResults of operative repair of complete atrioventricular canal defects (CAVCD) are improving due to: general advances in pre‐, intra‐, and postoperative care; a better understanding of the relevant pathological factors, principally of the left atrioventricular (A‐V) valve; a clearer definition of the path of the specialized conduction tissue; and the recognition of associated defects such as single left ventricular papillary muscles, ventricular hypoplasia, with or without malalignment of the common A‐V valve, coexistent ventricular septal defects, and double orifice left A‐V valves. Forty‐eight patients underwent repair from July 1980 through July 1984. Three patients died early and 2 late after the operation. One patient with an additional posterior ventricular septal defect (VSD) remained in complete heart block. Three patients required reoperation for residual left A‐V valve regurgitation and 1 for a residual VSD. In 20 recatheterized patients, mitral regurgitation was moderate in 4 and severe in 2. Pulmonary artery pressure (pulmonary/systemic arterial systolic pressure ratio) remained unchanged in only 1 patient with significant A‐V valve regurgitation. To avoid the development of pulmonary vascular obstructive disease, and based also on the trend of decreasing operative mortality and morbidity rates, primary repair of CAVCD is recommended within the first year of life.

Long-term evaluation after total correction of tetralogy of Fallot.

Cardiac functions of 28 patients long after correction of tetralogy of Fallot (TOF) were examined using non-invasive and invasive methods. For comparison the patients were grouped in 2 different ways: those with a right ventricular systolic pressure below 50 mmHg (Group A, n = 10) and above 50 mmHg (Group B, n = 18) in the early post-operative stage ; those having an ability to complete the treadmill test (Group I, n = 14) and those without it (Group II, n = 10). The following results were obtained by our study performed more than 10 years after surgery : 1) Group A showed no differences in all parameters studied as compared with Group B. 2) As compared with the normal subjects ( control group, n = 20), the patients had a larger cardio-thoracic ratio (CTR) and a larger right/left ventricular dimension ratio (RVD/LVD), but showed no differences in percent fractional shortening (%FS), mean velocity of circumferential fiber shortening (mVcf), corrected ejection time (ETc) and ejection fraction(EF). 3) As compared with Group I, Group II had a larger CTR, a larger RVD/LVD ratio, and continued higher levels of the right/left ventricular systolic pressure ratio (RVP/LVP) and right ventricular pulmonary systolic pressure gradient (PG), but showed no differences in %FS, mVcf, ETc, EF and pulmonary artery pulse pressure/pulmonary arterial systolic pressure ratio. 4) Eight patients, all belonging to Group II, , had ventricular arrhythmia (Lown's grade 3 or 4). 5) Severe pulmonary regurgitation (PR) was noted in Group II. At a later time long after the correction of TOF, RVP, PG, PR and arrhythmia are considered to be important parameters for evaluating the cardiac status in this disorder.

The early and late effects of surgical closure of ventricular septal defects on pulmonary vascular dynamics.

In sixty patients who underwent closure of ventricular septal defect (VSD), cardiac catheterizations were performed before and late after surgery together with pressure measurements immediately after closure of the VSD during surgery. Pulmonary arterial mean pressure (PAm), pulmonary arterial systolic pressure to systemic arterial systolic pressure ratio (Pp/Ps), and pulmonary vascular resistance to systemic vascular resistance ratio (Rp/Rs) were measured and calculated. The patients were classified into 5 groups according to the preoperative Rp/Rs and Qp/Qs as was reported by Nakada: Group A: Rp/Rs less than 0.15, Qp/Qs larger than or equal to 1.8, Group B: Rp/Rs less than 0.15, Qp/Qs less than 1.8, Group C: 0.15 less than or equal to Rp/Rs less than 0.50, Group D: 0.50 less than or equal to Rp/Rs less than 0.85, Group E: 0.85 less than or equal to Rp/Rs. These groups were further divided into 3 groups respectively according to age at operation (less than or equal to 2 years, 3 or 4 years, 5 years less than or equal to). The averages of PAm, Pp/Ps, and Rp/Rs were within the normal range in Group A and B patients (normal pulmonary vascular resistance groups) irrespective to the age at operation except the average of PAm before surgery. In Group C, D and E patients (elevated pulmonary vascular resistance group), these variables decreased immediately after closure of VSD, and further decreases were noted at the time of late catheterization. These variables, however, did not completely normalize even at that time. Among the patients operated upon at 2 years of age or less, the averages of these variables normalized immediately after closure of the VSD. When operated upon at 3 or 4 years of age, these variables decreased but did not normalize immediately after closure of the VSD and were found to be within the normal range at the time of late catheterization. When operated upon at 5 years of age or more, these variables decreased immediately after closure of the VSD, and further decrease was found at the time of late catheterization but mostly remained in the abnormal range even at this time. From the data obtained herein, the factors producing the pulmonary vascular resistances in respective age groups were discussed. The closure of VSD in patients with elevated pulmonary vascular resistance is recommended at the latest 4 years of age and preferably at 2 years of age or less, in order to obtain normal pulmonary circulatory dynamics after surgery.