Left Ventricle Right Ventricle Research Articles

Myocardial strain on admission predicts disease severity in infants hospitalized for bronchiolitis.

To assess cardiac function in infants with bronchiolitis and the association with disease severity and outcomes. Cardiac function may be impaired in bronchiolitis and represent an early predictor of disease severity. A prospective cohort study. Infants with suspected bronchiolitis were included. All cases received antigen detection and viral genome detection from nasal lavage or swabs and echocardiography within 24 hours from admission. Systolic and diastolic function in left ventricle (LV) and right ventricle (RV) were assessed using longitudinal strain (LS), a measure of myocardial deformation. Pulmonary artery pressures were estimated using tricuspid regurgitation jet (TR), when present, and end-systolic eccentricity index (EI ES). Main outcomes (duration of respiratory support, length of stay [LOS], and type of respiratory support) were collected. Data were compared to normative existing data, and a group of healthy infants, matched in age. Twenty-eight infants with bronchiolitis and 10 healthy comparators were included. Cases with bronchiolitis showed significantly lower values of RV LS and LV LS compared to healthy comparators (LV: p0.04 and RV: P < .001). Ten infants (36%) had a normal biventricular function, nine (32%) had LV impairment, and nine (32%) had a biventricular impairment. No significant differences were found in TR and EI ES. Infants with biventricular impairment demonstrated a significant increase in LOS (p0.04) and higher levels of respiratory support compared to the healthy comparators (P = .03). Bronchiolitis is associated with myocardial impairment. Cardiac function is related to disease severity and outcome.

Study of the relation between speckle tracking echocardiography and BODE index in patients with chronic obstructive pulmonary disease

Background Chronic obstructive pulmonary disease (COPD) is a widespread lung disease with a high mortality and morbidity especially with co-morbid cardiac impairment. Severity of COPD can be assessed using BODE Index (body mass index, obstruction of airflow, dyspnea degree and exercise capacity). Aim To study the relationship between BODE index and right ventricle (RV) and left ventricle (LV) functions using Two-dimensional speckle-tracking echocardiography (2D-STE) in COPD patients. Subjects and methods Fifty stable COPD patients and matched fifty control subjects underwent transthoracic echocardiography, where conventional and speckle tracking parameters were taken. BODE indices were calculated and divided to quartiles (Q) (Q1; BODE index = 0–2, Q2; BODE index = 3–4 Q3; BODE index = 5–6, Q4; BODE index = 7–10). Results COPD patients had lower RV fractional area change (FAC%, P Conclusion COPD patients had RV, LV systolic dysfunction and LV diastolic dysfunction. The more COPD severity increased (assessed by BODE index) the more impairment of RV systolic function and LV diastolic function would be.

Evaluation of cardiac function in pediatric patients with mild to moderate bronchial asthma in the era of cardiac strain imaging.

Bronchial asthma is a common chronic inflammatory airway disease, which may be associated with pulmonary hypertension and cardiac dysfunction. The aim of this study was to evaluate the ability of 2D-speckle tracking echocardiography (2D-STE) and tissue doppler imaging (TDI) to detect subtle cardiac dysfunction in pediatric patients with mild to moderate bronchial asthma. The study included 30 children with mild to moderate bronchial asthma and 27 age-matched healthy controls. Both groups underwent pulmonary function tests, TDI and 2D-STE. Myocardial performance index (MPI), S', E', A' velocities, global strain of left ventricle (LV), right ventricle (RV), and right atrium (RA) were measured. RV diastolic function was impaired in the patient group, as the tricuspid E' velocity was significantly lower in the patients when compared with the controls (16 [14-17] vs 16 [17-19] cm/s, P = .044), while the RV-MPI was significantly higher in patients when compared to controls (0.30 [0.27-0.36] vs 0.30 [0.30-0.30], P = .001). The global RV longitudinal strain, RA strain, and LV strain did not show significant differences between the test and the control groups. RV systolic parameters and LV systolic and diastolic parameters did not differ significantly between the two groups. Pediatric patients with mild to moderate bronchial asthma may have early RV diastolic dysfunction with preserved other cardiac functions.

Right ventricular function in infants with bronchopulmonary dysplasia and pulmonary hypertension: a pilot study.

Premature birth and bronchopulmonary dysplasia (BPD) are risk factors for the development of echocardiographic signs of pulmonary hypertension (PH) and are associated with changes in cardiac structure and function. It is unclear whether this association persists beyond early infancy. The aims of this study are to prospectively investigate the prevalence of PH in children with severe BPD and to investigate the effect of BPD and PH on myocardial structure and function at six months corrected age. Preterm infants (gestational age ≤ 32 weeks) with severe BPD were included. Echocardiography was used to define PH and to measure speckle tracking derived longitudinal and circumferential strain of the left ventricle (LV) and right ventricle (RV). Sixty-nine infants with a median (interquartile range [IQR]) gestational age of 25.6 (24.9–26.4) weeks and a median birthweight of 770 (645–945) gram were included. Eight (12%) infants had signs of PH at six months corrected age. RV fractional area change was lower in infants with severe BPD and PH at six months compared to infants without PH (35% ± 9% vs. 43% ± 9%, P = 0.03). RV mean longitudinal systolic strain was lower in infants with severe BPD and PH compared to infants without PH (17.6% [−19.5%/−16.1%] vs. −20.9% [−25.9%/−17.9%], P = 0.04). RV size and LV longitudinal and circumferential strain in children with BPD with or without PH were similar. Signs of PH were found in 12% of infants with severe BPD at six months corrected age and the presence of PH is associated with reduced RV systolic function.

Right ventricular dyssynchrony and its improvements after pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

Whether pathologic alterations of right ventricle (RV) in chronic obstructive pulmonary disease (COPD) affect intra- and interventricular dyssynchrony due to changes in mechanical activation of the septum and RV is unclear. The aim of this study was to determine mechanical activation and its changes after pulmonary rehabilitation program (PRP) with speckle tracking echocardiography (STE) in COPD patients. After the exclusion of 15 patients due to poor echogenicity and 5 patients not tolerating PRP out of 69 consecutive COPD patients undergoing PRP, the remaining 49 patients and 41 healthy subjects were enrolled. The mechanical activations of both ventricles were evaluated at admission and after PRP with STE. Chronic obstructive pulmonary disease patients had intra- and interventricular dyssynchrony compared to controls. The interventricular dyssynchrony assessed by time to peak longitudinal systolic strain (PLSS) difference between RV free wall and left ventricle (LV) lateral wall and intraventricular dyssynchrony assessed by RV peak systolic strain dyssynchrony (PSSD) index were improved after PRP. In all, 18 patients were hospitalized due to symptoms of right heart failure within 1year. The time to PLSS difference between RV free wall and LV lateral wall and RV PSSD index were independent predictors of hospitalization. Receiver operating characteristics (ROC) analysis revealed that a time to PLSS difference between RV free wall and LV lateral wall >15ms predicted hospitalization within 1year with 77.8% sensitivity and 64.5% specificity. Chronic obstructive pulmonary disease was associated with intra- and interventricular dyssynchrony. PRP had an important impact on the improvement of both intra-, and interventricular dyssynchrony, which might be used in predicting hospitalization within 1year.

The role of interventricular conduction delay to predict clinical response with cardiac resynchronization therapy

Pacing at sites with late electrical activation or greater interventricular delay is associated with improvement in measures of cardiac resynchronization therapy (CRT) response, primarily reverse remodeling. However, little is known about whether such lead positions improve heart failure (HF) clinical outcomes. The purpose of this study was to assess the association between interventricular electrical delay and HF clinical outcomes. The Pacing Evaluation-Atrial SUpport Study was a multicenter randomized trial of patients undergoing CRT-defibrillator implantation. Interventricular delay was measured as the unpaced right ventricle-left ventricle (RV-LV) interval in sinus rhythm. The HF clinical composite score was the primary end point. In addition, the time to first HF hospitalization or death was measured and events were adjudicated by a blinded core laboratory. The cohort was divided at the median RV-LV interval into short (<67 ms) and long (≥67 ms) subgroups. In addition, receiver operating characteristic curves were constructed to identify the optimal cutoff of the RV-LV interval and spline analysis was performed to assess RV-LV interval as a continuous variable. A total of 1342 patients were included in this study. The clinical composite score at 1 year differed between groups, with more patients improving and fewer patients worsening in the long RV-LV group (P = .014). The time to first HF hospitalization or mortality also differed with a lower risk of an event in the long RV-LV group (hazard ratio 0.62; P = .002). Multivariate analysis showed that RV-LV time (hazard ratio 0.71; P = .038) and sex were independent predictors of this outcome. Baseline interventricular delay is a strong independent predictor of clinical response to CRT.

Changes in Strain Pattern and Exercise Capacity after Transcatheter Closure of Atrial Septal Defects.

Background and ObjectivesAssessment of left ventricle (LV) function by using strain and strain rate is popular in the clinical setting. However, the use of these echocardiographic tools in assessing right ventricle (RV) failure, and the manner in which they both reflect the functional capacity of the patient, remains poorly understood. This study aimed to investigate the change in exercise capacity and strain between before and (1 month) after the transcatheter closure of atrial septal defects (ASDs).Subjects and MethodsThirty patients who underwent transcatheter closure of ASD between May 2014 and June 2015 at the Division of Pediatric Cardiology, Severance Cardiovascular Hospital, were enrolled. We compared and analyzed the results of the following examinations, before and (1 month) after the procedure: echocardiography, cardiopulmonary exercise test (CPET), and N-terminal pro-brain natriuretic peptide level.ResultsThere were no mortalities, and the male-to-female ratio was 1:2. The mean defect size was 22.3±4.9 mm; the mean Qp/Qs ratio, 2.1±0.5; and the mean device size, 22.3±4.9 mm. Changes in global RV longitudinal (GRVL) strain and LV torsion were measured echocardiographically. Exercise capacity improved from 7.7±1.2 to 8.7±1.8 metabolic equivalents (p=0.001). These findings correlated to the change in GRVL strain (p=0.03).ConclusionThe average exercise capacity increased after device closure of ASD. The change in strain was evident on echocardiography, especially for GRVL strain and LV torsion. Further studies comparing CPET and strain in various patients may show increased exercise capacity in patients with improved RV function.

Interventricular Electrical Delay IsPredictive of Response to CardiacResynchronizationTherapy.

This study was conceived to evaluate the relationship between interventricular electrical delay, as measured by the right ventricle-left ventricle (RV-LV) interval, and outcomes in a prospectively designed substudy of the SMART-AV (SMARTDELAY determined AV Optimization) trial. Despite the well-documented benefit of cardiac resynchronization therapy (CRT), the nonresponder rate remains an important clinical problem. Implanting LV leads by traditional anatomic criteria has limited impact on outcomes. However, pacing at sites with late electrical activation improves CRT response rates. Thus, we hypothesized that interventricular electrical delay is associated with improved CRT outcomes. This was a multicenter study of patients with advanced heart failure undergoing CRT implantation. In 419 subjects, the unpaced RV-LV interval was measured in sinus rhythm. LV volumes and ejection fraction were measured by echocardiography at baseline and after 6 months of CRT by a blinded core laboratory. Quality of life (QOL) was assessed by a standardized questionnaire. When separated by quartiles based on interventricular delay, the magnitudes of LV volumes, ejection fraction and the QOL measure increased significantly with prolongation of RV-LV delay (p< 0.05). The LV end-systolic volume response rate increased progressively from 30% to 75% (p< 0.001), and the QOL response rate increased from 50% to 65% (p= 0.08). Patients in the highest quartile of RV-LV had a 5.98-fold increase (p< 0.001) in their odds of a reverse remodeling response, with female sex, ischemic etiology, and baseline LV end-systolic volume being the other independent predictors of response. Baseline interventricular delay is a potent independent predictor of remodeling and QOL responses with CRT.

Analysis of fetal echocardiography parameters in the diagnosis of fetal aortic coarctation

Objective To explore the diagnostic sensitivity and specificity of echocardiography parameters, and the diagnostic value of multiple parameters score. Methods Forty-nine cases of the fetus checked by fetal echocardiography and were indicated aortic coarctation. According to the results of follow-up, the cases were divided into the positive and negative groups. Comprehensive analysis were performed in fetal echocardiography parameters, such as diameter ratio and velocity ratio of ventricle, aorta, pulmonary artery, ductus artery, middle cerebral artery and umbilical artery. Results Diameter ratio of left ventricle/right ventricle(LV/RV), pulmonary artery/aorta(PA/AO), aortic isthmus/ductus artery(AI/DA), and velocity ratioof middle cerebral artery/inner umbilical artery(MCA/inUA) were calculated, ROC curve showed their area under ROC were>0.5 with a significant statistical significance (P<0.05). The Chi-square test showed that the consistency of any single ratio was relatively low. When the number of the ratiois increased to 3-4, the Kappa value was 0.687(P=0.000) and 0.649(P=0.000), respectively, which had relatively high diagnostic value. Conclusions Ultrasonic diagnosis of fetal coarctation of aorta has certain difficulty, and the value of single hemodynamic parameter of fetal echocardiography in diagnosis of fetal aortic coarctation is lower, so that the comprehensive evaluation and combined multiple ultrasonic parameters can improve the sensitivity and specificity of ultrasound diagnosis. Key words: Echocardiography; Fetal heart; Aortic coarctation

The impact of cisplatinum-based chemotherapy on ventricular function and cardiovascular risk factors in female survivors after malignant germ cell cancer.

AimsAmong male cancer survivors, cisplatinum‐based chemotherapy (CBCT) is associated with impaired left ventricle (LV) diastolic function, increased risk of metabolic syndrome, and increased cardiovascular morbidity and mortality. Comparable data in females are limited. The long‐term effects of cisplatin on right ventricle (RV) function are unknown in both genders. We aimed to investigate the impact of CBCT on cardiovascular risk factors and cardiac function in female survivors after malignant ovarian germ cell tumour (MOGCT).Methods and resultsThis national cross‐sectional follow‐up study recruited MOGCT survivors, diagnosed from 1980–09 (n = 153). Seventy‐four (48%) participated in out‐patient visit, of whom 41 had received CBCT (62% of all CBCT): median age, 35 years (range, 18–64 years); median time since CBCT, 14 years (range, 5–31 years). Participants were categorized into high‐CBCT (n = 19) and low‐CBCT (n = 22) groups and compared with age‐matched healthy females. All participants underwent laboratory tests and echocardiography to determine cardiac function. Compared with low‐CBCT participants, the high‐CBCT group showed significantly impaired RV function, as evaluated by tricuspid annular plane systolic excursion (22.6 ± 2.4 mm vs. 26.3 ± 3.6 mm; P < 0.001); RV S' (10.7 ± 1.9 cm/s vs. 12.4 ± 2.3 cm/s; P = 0.01); RV global longitudinal strain (−23.4 ± 2.4% vs. −25.7 ± 3.7%; P = 0.02), and tricuspid annular displacement (21 ± 2 mm vs. 24 ± 3 mm; P = 0.001). LV diastolic function was impaired in the high‐CBCT group compared with controls. Patients and controls exhibited similar metabolic syndrome prevalences.ConclusionsAmong long‐term survivors of MOGCT, CBCT was associated with impaired RV function and LV diastolic function. Unlike men, women do not appear to have an elevated risk of metabolic syndrome after CBCT.

Correlation of D-dimer level with the radiological severity indexes of pulmonary embolism on computed tomography pulmonary angiography

Background It is known that the main role of D-dimer has been as an exclusionary test in patients with suspected venous thromboembolism. However, the D-dimer is increasingly beginning to find clinical utility as a marker in the evaluation of the extent of the embolic disease. The aim of the study was to determine whether D-dimer levels predict the radiological markers of pulmonary embolism (PE) severity using Mastora score. Methods This prospective study involved 69 patients with acute PE proved by computed tomography pulmonary angiography (CTPA). The D-dimer level was noted. A pulmonary artery obstruction index (PAOI; Mastora score) ≥21.3% indicated severe obstruction of PE. A right ventricle/left ventricle (RV/LV) ratio &gt;0.9 indicated RV dysfunction. Results The median D-dimer level and PAOI were 765 μg/L (95% CI: 750–1 205 μg/L) and 16.77% (95% CI: 16.32%-23.06%), respectively. The D-dimer level was positively correlated with PAOI (r=0.417, P &lt;0.000 1). PAOI ≥21.3% was associated with high D-dimer levels (median, 993 μg/L (95% CI: 856–1 841 μg/L), Z=-2.991, P=0.003). The D-dimer level was correlated with the RV/LV ratio (r=0.272, P=0.024). RV/LV ratios &gt;0.9 were associated with high D-dimer levels (median, 880 μg/L (95% CI: 764–1 360 μg/L), Z=-2.070, P=0.038). PAOI was positively correlated with the RV/LV ratio (r =0.390, P=0.001). After three months, both the PAOI and D-dimer levels decreased (Z=-7.009, P &lt;0.000 1; Z=-6.976, P &lt;0.000 1, respectively). Conclusion D-dimer levels are positively correlated with PE burden and right ventricle dysfunction on CTPA, and can help monitor the therapeutic response.

Distribución de síntomas en pacientes con TEP según su relación VD/VI en angiografías por tomografías computadas

Background: Pulmonary embolism (PE) is a frequent and mortal condition if not managed properly. Symptoms are various and some are associated with severity in PE. Computed tomography angiography (AngioCT) is the most used imaging technique to diagnose and&#x0D; estimate the severity in PE. Objective: Describe the distribution of symptoms in patient with RV/LV (right ventricle/left ventricle)&gt;1 or 1 of which 62% were female. Symptoms in RV/LV&gt;1 patients: lower extremities pain or swelling: 46%, dyspnea: 31%, cough: 23%, palpitation: 8%, presyncope: 8%, 31% of patient had multiple symptoms. Symptoms in RV/LV1 patients. Other symptoms than lower extremities pain or swelling or dyspnea were more frequent in RV/LV&gt;1 . In RV/LV

Electrocardiographic T Wave and its Relation With Ventricular Repolarization Along Major Anatomical Axes

The genesis of the electrocardiographic T wave is incompletely understood and subject to controversy. We have correlated the ventricular repolarization sequence with simultaneously recorded T waves. Nine pig hearts were Langendorff-perfused (atrial pacing, cycle length 650 ms). Local activation and repolarization times were derived from unipolar electrograms sampling the ventricular myocardium. Dispersion of repolarization time was determined along 4 anatomic axes: left ventricle (LV)-right ventricle (RV), LV:apico-basal, LV:anterior-posterior, and LV:transmural. The heart was immersed in a fluid-filled bucket containing 61 electrodes to determine Tp (Tpeak in lead of maximum integral), TpTe (Tp to Tend), and TpTe_total (first Tpeak in any lead to last Tend in any lead). Repolarization was nonlinearly distributed in time. RT25 (time at which 25% of sites were repolarized, 288±26 ms) concurred with Tp. TpTe was 38±8 ms, and TpTe_total was 75±9 ms. TpTe_total correlated with dispersion of repolarization time in the entire heart (73±18 ms), but not with dispersion of repolarization times along individual axes (LV-RV, 66±17 ms; LV:apico-basal, 51±18 ms; LV:anterior-posterior, 51±27 ms; mean LV:transmural, 14±7 ms; all n=9). We provide a correlation between local repolarization and T wave in a pseudo-ECG. Repolarization differences along all anatomic axes contribute to the T wave. TpTe_total represents total dispersion of repolarization. At Tp, ≈25% of ventricular sites have been repolarized.

Right- and Left-Ventricular Strain Evaluation in Repaired Pediatric Tetralogy of Fallot Patients Using Magnetic Resonance Tagging

Residual pulmonary insufficiency in post-repair Tetralogy of Fallot (rToF) patients often mediates biventricular dysfunction which is associated with long-term adverse clinical outcomes. The objective of this study was to demonstrate the presence of impaired left ventricle (LV) circumferential strain (CS) in pediatric rToF patients as compared to controls using cardiac magnetic resonance imaging (CMRI). Additionally, bivariate analysis between right ventricle (RV) and LV functional measures in rToF patients was performed to further characterize the interventricular interactions thought to mediate LV dysfunction secondary to RV volume overload. The medical records of 12 rToF patients (mean age 13.3 years) and 9 controls (mean age 10.9 years) were analyzed. LV global CS was significantly decreased in rToF patients versus controls (p = 0.04). This impairment was differentially distributed within the LV, with only the LV anterior and anterior lateral walls significantly decreased versus controls (p = 0.04, p = 0.03). Bivariate analysis revealed a significant correlation between RV mean CS and LV EF (r = 0.71, p = 0.01), RV infundibulum CS and LV EF (r = 0.70, p = 0.01), RV infundibulum CS and LV anterolateral wall CS (r = 0.59, p = 0.04), and RV infundibulum CS and pulmonary regurgitation fraction (r = -0.63, p = 0.03). These findings support existing research implicating interventricular interactions in the development of LV dysfunction. Furthermore, the segment specific CS impairment in the LV suggests a possible spatial component to these interactions. The success of this study in identifying regional myocardial strain impairment indicates CMRI based techniques may be useful in localizing otherwise undetectable myocardial dysfunction.

Akut Pulmoner Emboli Hastalarında Pulmoner Arter Bilgisayarlı Tomografi Anjiyografi Obstrüksiyon Skorunun Hematolojik Bulgular ve Mortalite ile Korelasyonu

Objective: The aim of this study was to determine the relationship between the computed tomography obstruction score and radiological parameters, biochemical parameters, and mortality. Material and Methods: During an 8-month period (January 2011-August 2011), 326 patients with clinically suspected pulmonary embolism (PE) were examined by computerized tomography pulmonary angiography (CTPA). Of these patients, only 95 (49 men and 46 women) were diagnosed with PE. Computerized tomography images were retrieved from the picture archiving and communication system (PACS) for the determination of right ventricle/left ventricle (RV/LV) short-axis ratio, maximum diameter of the pulmonary artery, and vascular obstruction score according to Qanadli method. We investigated the correlation between continuous values of the Qanadli scoring system and mortality, and determined whether there was a significant difference between mortality and CTPA parameters. The values derived from the morphologic changes in the CTPA, hematological findings and gender where then assessed with respect to their impacts on mortality. Results: There was a significant correlation between the PE obstruction score and RV/LV short-axis ratio (r=0.58, p<0.001), RV/LV short-axis ratio, and neutrophil to lymphocyte ratio (NLR) (r=0.21, p=0.035). Survivors and non-survivors had a statistically significant difference in the NLR and mid?platelet volume (MPV) (p<0.05). The mortality incidence in patients with an increased MPV (odds ratio 1.689; 95% confidence interval (CI) 1.06-2.67; p=0.025) and older female patients (odds ratio 3.732; 95% CI 1.02-13.65; p=0.04) was higher. Conclusion: Our results suggest that in patients with acute PE, NLR and MPV may be of value for the estimation of mortality.

Tetralogy of Fallot with an abnormal coronary artery: surgical options and prognostic factors

The objectives were to determine in patients with Tetralogy of Fallot (ToF) and abnormal coronary artery (ACA): the long-term outcomes of different surgical strategies; the risk factors for right ventricular outflow tract (RVOT) obstruction, reoperation, heart failure and mortality. To date, the surgical strategies and prognostic factors for repair of ToF with an ACA, crossing the RVOT and avoiding a classic repair, have not been evaluated in a large series using a multivariate analysis. A retrospective study (1986-2011) included 72 patients. The mean follow-up was 9.6 ± 6.8 years. Median age at surgery was 1.5 years (0.2-11.3). The main surgical techniques were 'tailored' right ventriculotomy and patch of the RVOT (63%; n = 45), implantation of a conduit between the right ventricle (RV) and the pulmonary artery (PA; 25%; n = 18) and a transatrial ± transpulmonary approach (11%; n = 8). Univariate and multivariate logistic regression analyses were performed. Intrahospital mortality was 2.7%. Actuarial freedom from reoperation and actuarial survival at 15 years were 77% (confidence interval [CI]: 70-83%) and 94% (CI: 90-97%), respectively. Reoperations occurred more frequently after conduit implantation (50%) than after patch reconstruction (17%) or transatrial ± transpulmonary approach (0%; P = 0.002). The transatrial ± transpulmonary approach was significantly less complicated, with a long-term RVOT obstruction of 0% compared with the other surgical techniques (45.4%; P = 0.03). Implantation of a RV-PA conduit was an independent risk factor for RVOT obstruction (odds ratio [OR]: 31; P < 0.001) and reoperation (OR: 20; P = 0.02). An immediate postoperative right ventricle/left ventricle (RV/LV) pressure ratio >0.5 was independently associated with a long-term RV/LV pressure ratio >0.5 (OR: 14; P = 0.001), but was not a risk factor for reoperation (P = 0.8). Postoperative electric ischaemic signs independently increased the risk of long-term heart failure (OR: 22; P = 0.04). The transatrial ± transpulmonary approach displays the best long-term outcomes, by reducing the risks for RVOT obstruction and reoperation, but does not improve the patient survival. A RV-PA conduit was an independent risk factor for RVOT obstruction and reoperation. An immediate postoperative RV/LV pressure ratio >0.5 was not a risk factor for reoperation. The transatrial ± transpulmonary approach should be preferred to the implantation of a conduit or a tailored right ventriculotomy whenever possible.

Prognostic value of perfusion defect volume at dual energy CTA in patients with pulmonary embolism: Correlation with CTA obstruction scores, CT parameters of right ventricular dysfunction and adverse clinical outcome

PurposeTo investigate the prognostic value of perfusion defect volume (PDvol) at dual-energy-CT-angiography (DE-CTA) in patients with acute pulmonary embolism (PE) by correlating PDvol with CTA-obstruction-scores (OS), CT parameters of right-ventricular-dysfunction (RVD), and adverse-clinical-outcome. Materials and methodsDE-CTA of 60 patients (mean age: 65±14.4 years) with PE were analyzed. Iodine maps were generated, and normalized PDvol – defined as volume of perfusion defects/total lung volume – was quantified. Furthermore, established prognostic parameters (Qanadli and Mastora-OS, and CT parameters of RVD) were obtained. CT parameters of RVD – namely the right ventricle/left ventricle (RV/LV) diameter ratio measured on transverse sections (RV/LVtrans), four-chamber views (RV/LV4ch), and RV/LV volume ratios (RV/LVvol) – were assessed. PDvol was correlated with OS, CT parameters of RVD and adverse clinical outcome (defined as the need for intensive care treatment or death). Results10 of 60 patients with PE experienced adverse clinical outcome. Patients with adverse clinical outcome showed significantly higher PDvol (35±11% vs. 23±10%, p=0.002), RV/LV ratios (RV/LV4ch 1.46±0.32 vs. 1.18±0.26, p=0.005; RV/LVvol 2.25±1.33 vs. 1.19±0.56, p=0.002) and higher Mastora global scores (52 vs. 13, p=0.02) compared to those without adverse clinical outcome. A weak correlation was observed between PDvol and the Mastora global score (r=0.5; p=0.0003), as well as between PDvol and RV/LV4Ch (r=0.432, p=0.0006). No correlation was found between PDvol and the Qanadli score or the remainder of the RVD-CT parameters. ConclusionThe extent of perfusion defects as assessed by DE-CTA correlates with adverse clinical outcome in patients with PE. Therefore, volumetric quantification of perfusion defects at DE-CTA allows the identification of low-risk patients who do not require intensified monitoring and treatment.

Left-to-right ventricular differences in IKATP underlie epicardial repolarization gradient during global ischemia

The ionic mechanisms of electrical heterogeneity in the ischemic ventricular epicardium remain poorly understood. This study sought to test the hypothesis that the adenosine triphosphate (ATP)-activated K+ current (I(KATP)) plays an important role in mediating repolarization differences between the right ventricle (RV) and left ventricle (LV) during global ischemia. Electrical activity in Langendorff-perfused guinea pig hearts was recorded optically during control, ischemia, and reperfusion. Patch-clamp experiments were used to quantify I(KATP) density in isolated myocytes. Molecular correlates of I(KATP) (Kir6/SUR) were probed via reverse transcriptase-polymerase chain reaction. The role of I(KATP) in modulating repolarization was studied using computer simulations. Action potential duration (APD) was similar between LV and RV in control hearts, but significantly different in global ischemia. Pretreatment of hearts with 10 μM glibenclamide (I(KATP) blocker) abolished the APD gradient during ischemia. In the absence of ischemia, pinacidil (I(KATP) opener) tended to shorten the APD more in the LV, and caused a small but significant increase in APD dispersion. In voltage clamp experiments, the density of the whole-cell current activated by pinacidil at depolarized potentials was significantly larger in LV, compared with RV epicardial myocytes. The mRNA levels of Kir6.1/Kir6.2 were significantly higher in LV compared with RV. Simulations showed that I(KATP) is the main determinant of LV-RV APD gradient, whereas cell-to-cell coupling modified the spatial distribution of this APD gradient. I(KATP) is an important determinant of the epicardial LV-RV APD gradient during global ischemia, in part due to a higher current density and molecular expression in the LV.

Assessment of a right-ventricular infundibulum-sparing approach in transatrial–transpulmonary repair of tetralogy of Fallot

The study aimed to evaluate the outcome of transatrial-transpulmonary repair of tetralogy of Fallot in relation to a right-ventricular outflow tract (RVOT)-sparing surgery. Based on the surgical management of right-ventricular outflow tract obstruction (RVOTO) at repair of tetralogy of Fallot, 140 children were retrospectively divided into three groups: (1) pulmonary valve (PV)-sparing, (2) infundibulum-sparing and (3) extended trans-annular patch (TAP). Clinical and echocardiographic outcome was assessed with regards to three equally divided study time eras between January 1994 and June 2010. Over a 15-year study period, median age decreased from 11 (2-101) to 5 (1-11) months (p<0.001), whereas type of RVOT repair changed significantly between the first and the last era (group 1: 18-40%, group 2: 25-40% vs group 3: 57-20% (p=0.002)). Mortality was 0%. Complications were mainly related to clinical restrictive RV physiology (27%) and arrhythmia (10%). This cardiac morbidity remained constant over the eras and was associated with younger age (p=0.04), increased postoperative right ventricle/left ventricle (RV/LV) pressure ratio (p=0.01) and type of RVOT repair at the cost of TAP (p=0.03). Median follow-up of 8 years (1-16 years) showed an overall freedom from RVOT re-operation of 84% and 73%, respectively at 5 and 10 years. Most re-operations were for residual/recurrent RVOTO (12%) occurring more frequently in the latter era: 16% versus 7% in era 1 (p=0.08). Late echocardiographic evaluation revealed a strong correlation between severity of pulmonary regurgitation and increased RV/LV size ratio, which was mainly determined by increased TAP length (p<0.001) and duration of follow-up (p=0.06). In a 15-year's experience with transatrial-transpulmonary correction of tetralogy of Fallot, a valve- and infundibulum-sparing approach has been advanced by lowering the age for elective repair. This change has been performed without compromising immediate clinical outcome, despite an increased early re-operation rate for residual obstruction. However, longer follow-up will disclose whether this approach is protective against progressive and late RV dysfunction.

Acute effects of pacing site on repolarization and haemodynamics of the canine ventricles

To determine the repolarization duration gradients in different ventricular regions at atrial and ventricular pacing and to test the hypothesis that acute haemodynamic response to ventricular pacing is related to the lead position with respect to repolarization gradients. Repolarization durations estimated as activation-recovery intervals (ARIs) were measured from unipolar electrograms recorded in the subepicardial (Epi), mid-myocardial (Mid), and subendocardial (Endo) layers of the apical and basal parts of the right ventricle (RV) and left ventricle (LV) of 15 healthy dogs under atrial and ventricular pacing. Cardiac haemodynamic variables were measured as well. At atrial pacing, ARIs were shorter in Epi than in the innermost layers (P< 0.05) in the RV apex and LV base, but not in the LV apex and RV base. Activation-recovery intervals increased from apex to base and from base to apex in RV and LV, respectively (P ≤ 0.05). At apical or basal pacing of RV and LV, repolarization gradients decayed. The dispersion of repolarization increased at LV apical pacing and preserved at RV apical pacing. The pump function of a ventricle was altered dramatically at pacing of the area with the shorter ARIs and to a lesser degree at pacing of the area with the longer ARIs (P ≤ 0.051). The transmural and apicobasal differences in repolarization durations were heterogeneously distributed at atrial pacing. The acute haemodynamic response of the individual ventricle was better with pacing of the region with the longest repolarization suggesting a promising criterion for the lead position selection on the basis of ARIs measurements.