Changes in right ventricular geometry and heart rate early after hemi-Fontan procedure

doi:10.1016/0003-4975(93)91099-9

The Annals of Thoracic Surgery

Volume 55, Issue 6, June 1993, Pages 1508-1512

https://doi.org/10.1016/0003-4975(93)91099-9 Get rights and content

Abstract

To document and quantitate changes in right ventricular (RV) geometry and heart rate, we prospectively examined 35 consecutive patients with hypoplastic left heart syndrome under steady-state conditions (chloral hydrate sedation) before and after a bidirectional cavopulmonary anastomosis (hemi-Fontan) procedure. Right ventricular end-diastolic volume (RVEDV) was calculated as the product of RV cavity areas in two orthogonal planes divided by RV maximal length in either plane. After the hemi-Fontan procedure, RVEDV decreased by 33% from 33 ± 13 to 22 ± 11 mL (mean ± standard deviation). Indexed RVEDV decreased from 86 ± 37 to 57 ± 28 mL/m². The RV wall thickness at the diaphragm in subcostal frontal view (RVWD) increased by only 11% from 8 ± 0.2 to 9 ± 0.2 mm (p = not significant), but RVWD/RVEDV increased by 111% from 0.36 ± 0.22 to 0.76 ± 0.69 mm/ml (p = 0.002). The RV anterior wall thickness in subcostal sagittal view (RVWA) increased by only 13% from 7 ± 0.2 to 8 ± 0.2 mm (p = not significant), but RVWA/RVEDV increased by 103% from 0.31 ± 0.20 to 0.63 ± 0.54 mm/mL (p = 0.002). In 11 of 35 patients (31%), resting heart rate did not change (118 ± 14 versus 108 ± 9 beats/min; p = not significant); however, in 24 of 35 patients (69%), heart rate increased significantly (108 ± 9 versus 127 ± 10 beats/min; p = 0.05). In conclusion, RV wall thickness is high before the hemi-Fontan procedure and increases slightly in the first post-operative week. A concomitant decrease in RVEDV results in a marked change in RV geometry. There is usually a significant increase in resting heart rate as well. Thus, early postoperative chances in RV geometry may have a hemodynamically important impact on stroke volume.

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Cited by (56)

Attrition between the superior cavopulmonary connection and the Fontan procedure in hypoplastic left heart syndrome
2021, Journal of Thoracic and Cardiovascular Surgery
We investigated the incidence and predictors of failure to undergo the Fontan in children with hypoplastic left heart syndrome who survived superior cavopulmonary connection.
The cohort consists of all patients with hypoplastic left heart syndrome who survived to hospital discharge after superior cavopulmonary connection between 1988 and 2017. The primary outcome was attrition, which was defined as death, nonsuitability for the Fontan, or cardiac transplantation before the Fontan. Subjects were excluded if they were awaiting the Fontan, were lost to follow-up, or underwent biventricular repair. The study period was divided into 4 eras based on changes in operative or medical management. Attrition was estimated with 95% confidence intervals, and predictors were identified using adjusted, logistic regression models.
Of the 856 hospital survivors after superior cavopulmonary connection, 52 died, 7 were deemed unsuitable for Fontan, and 12 underwent or were awaiting heart transplant. Overall attrition was 8.3% (71/856). Attrition rate did not change significantly across eras. A best-fitting multiple logistic regression model was used, adjusting for superior cavopulmonary connection year and other influential covariates: right ventricle to pulmonary artery shunt at Norwood (P < .01), total support time at superior cavopulmonary connection (P < .01), atrioventricular valve reconstruction at superior cavopulmonary connection (P = .02), performance of other procedures at superior cavopulmonary connection (P = .01), and length of stay after superior cavopulmonary connection (P < .01).
In this study spanning more than 3 decades, 8.3% of children with hypoplastic left heart syndrome failed to undergo the Fontan after superior cavopulmonary connection. This attrition rate has not decreased over 30 years. Use of a right ventricle to pulmonary artery shunt at the Norwood procedure was associated with increased attrition.
Influence of bidirectional cavopulmonary anastomosis and concomitant valve repair on atrioventricular valve annulus and function
2014, Annals of Thoracic Surgery
The relationship between atrioventricular valve regurgitation (AVVR) and valve annulus after bidirectional cavopulmonary anastomosis (BCPA) and adequate indications for valve repair are unclear.
We evaluated the size of the valve annulus and the grade of AVVR before and immediately after BCPA, and at the most recent follow-up before the Fontan operation in 37 patients with a functional single ventricle.
Nine patients underwent concomitant valve surgery. The mean z value of the valve annulus was significantly lower postoperatively than preoperatively in the 28 patients who were not treated by valve surgery (0.45 vs 1.51, p = 0.01). However, mean regurgitation scores did not significantly change after BCPA (1.60 vs 1.78, p = 0.08). The most recent assessment showed that the mean z value increased compared with that immediately after BCPA (1.36 vs 0.45, p = 0.005). This increase was significant in the patients with moderate regurgitation. The mean z value of the valve annulus of the patients treated by concomitant valvuloplasty was significantly lower postoperatively than preoperatively (−0.25 vs 3.9, p = 0.0001) and remained low at the latest evaluation. Mean regurgitation scores also significantly decreased after BCPA (2.25 vs 3.37, p = 0.007).
Unloading the systemic ventricle by BCPA leads to a decrease in the relative size of the atrioventricular valve. However, this decrease does not improve the degree of AVVR in the absence of concomitant valve repair. Concomitant valve repair is justified in patients with moderate or worse AVVR and an abnormal valve structure.
Impact of Blalock-Taussig shunt size on tricuspid regurgitation in hypoplastic left heart syndrome
2014, Annals of Thoracic Surgery
Citation Excerpt :
The prevention of TR is therefore important in improving the long-term outcomes for these patients. Previous studies have demonstrated that ventricular volume decreases significantly after BCPC [17] or Fontan completion [18, 19]. Seliem and colleagues [17] reported that the RV end-diastolic volume decreases by 33% after BCPC.
The prognosis for hypoplastic left heart syndrome (HLHS) has greatly improved over the past years, but there is still a significant risk of interstage mortality. Tricuspid valve regurgitation (TR) is known to be a risk factor for interstage mortality. We hypothesized that a modified Blalock-Taussig (BT) shunt with a smaller diameter would lead to a reduction in ventricular volume loading with a consequent reduction in TR.
A retrospective review of all patients with HLHS who had a Norwood procedure in our institution between 2006 and 2011 was performed. Patient demographic, echocardiographic, cardiac magnetic resonance imaging, and operative data were reviewed. The impact of BT shunt diameter on severity of TR at the time of bidirectional cavopulmonary connection (BCPC) was analyzed.
Sixty-four neonates with HLHS underwent a Norwood procedure with a BT shunt. Thirty-two had a 3.5-mm BT shunt (3.5-mm group), and 32 had a 3.0-mm BT shunt (3.0-mm group). Survival to BCPC was 53 of 64 patients (83%) overall, with 25 of 32 patients (78%) in the 3.5-mm group and 28 of 32 (88%) in the 3.0-mm group (p = 0.51). The prevalence of significant TR (moderate or higher) before BCPC was 9 of 25 patients (36%) in the 3.5-mm group and 2 of 28 patients (7%) in the 3.0-mm group (odds ratio = 7.3; 95% confidence interval: 1.4–38; p = 0.018). Tricuspid valve repair was performed in 4 of 25 patients (16%) in the 3.5-mm group and 2 of 28 patients (7%) in the 3.0-mm group (p = 0.21).
A smaller-diameter BT shunt reduces the prevalence of significant TR at the time of BCPC. Further investigation and long-term follow-up are required to determine potential complications of this surgical strategy.
Unloading of right ventricle by bidirectional superior cavopulmonary anastomosis in hypoplastic left heart syndrome patients promotes remodeling of systemic right ventricle but does not improve tricuspid regurgitation
2012, Journal of Thoracic and Cardiovascular Surgery
To evaluate the influence of volume unloading by bidirectional superior cavopulmonary anastomosis on the systemic right ventricle in patients with hypoplastic left heart syndrome.
A total of 90 consecutive patients with hypoplastic left heart syndrome, who had survived the early postoperative period after bidirectional superior cavopulmonary anastomosis, were studied. Seven patients were excluded because of tricuspid valve surgery before or in association with bidirectional superior cavopulmonary anastomosis. The echocardiograms of the remaining 83 patients were reevaluated for tricuspid valve regurgitation and the size of the tricuspid annulus before bidirectional superior cavopulmonary anastomosis and at the last available follow-up examination before total cavopulmonary connection.
Echocardiograms were performed a median of 5 days before bidirectional superior cavopulmonary anastomosis. Tricuspid valve regurgitation was graded as 0 in 11 patients, I in 37 patients, II in 24 patients, and III in 11 patients. Follow-up echocardiograms were performed a median of 17 months after bidirectional superior cavopulmonary anastomosis. Postoperatively, tricuspid valve regurgitation was graded as 0 in 14 patients, I in 37 patients, II in 21 patients, III in 6 patients, and IV in 5 patients. Postoperatively, the mean Z value of the tricuspid annulus stayed the same in patients with significant tricuspid valve regurgitation (grade III or IV) after bidirectional superior cavopulmonary anastomosis but had decreased in the remaining patients. No significant change was seen in the level of tricuspid valve regurgitation after bidirectional superior cavopulmonary anastomosis compared with the preoperative data.
The relative size of the tricuspid annulus in patients with hypoplastic left heart syndrome decreases after bidirectional superior cavopulmonary anastomosis, most likely owing to volume unloading and promotion of the remodeling of the systemic right ventricle. However, this remodeling of the right ventricle does not improve the grade of tricuspid regurgitation.
Serial assessment of right ventricular volume and function in surgically palliated hypoplastic left heart syndrome using real-time transthoracic three-dimensional echocardiography
2012, Journal of the American Society of Echocardiography
Citation Excerpt :
In the setting of HLHS, at least three factors are responsible for these changes: (1) chronic pressure overload, (2) attrition of myocardial function with each surgical intervention or clinical crisis, and (3) ventricular dilation leading to tricuspid regurgitation. There are reports of decreasing stroke volume after SP2,27,28 but data on volume unloading after SP2 in patients with HLHS are scarce. In a prospective CMR study, ventricular volumes 6 to 9 months after SP2 (hemi-Fontan procedure) were not statistically different from pre-hemi-Fontan data,16 and this matches our observations.
Right ventricular (RV) failure is a major cause of morbidity and mortality in patients with hypoplastic left heart syndrome (HLHS), but the longitudinal course of RV volumes through staged palliation (SP) has not been previously investigated. The aim of this study was to evaluate RV volume and function longitudinally through SP of HLHS using real-time three-dimensional echocardiography.
A total of 18 subjects with HLHS were prospectively studied at four time points from diagnosis through stage 2 (SP2). Real-time three-dimensional echocardiographic full-volume data sets were acquired in high–frame rate mode with electrocardiographic gating. Volumetric and functional analyses were performed using a semiautomatic contour detection algorithm. Eighteen age-matched and sex-matched normal infants (aged 0–6 months) were studied at comparable time points as controls.
Presurgical examinations (pre–stage 1 [SP1]; n = 18) were performed at a mean age of 4 days, post-SP1 examinations (n = 17) at a mean age of 20 days, pre-SP2 examinations (n = 14) at a mean age of 4.6 months, and post-SP2 examinations (n = 14) at a mean age of 5.5 months, constituting a total of 63 examinations. The mean values of RV end-diastolic volume indexed to body surface area (EDVi) at the four time points were 87 ± 30, 104 ± 39, 112 ± 34, and 102 ± 35 mL/m², respectively. There was an increase in EDVi (P = .024) from pre-SP1 to post-SP1 but no significant change between post-SP1 and pre-SP2. The decrease in EDVi after SP2 did not reach statistical significance. Mean RV ejection fractions (EFs) were 50 ± 5%, 45 ± 5%, 46 ± 5%, and 38 ± 4%, respectively. There was a trend toward decreasing EF throughout SP, with statistically significant decreases from pre-SP1 to post-SP1 (P = .003) and from pre-SP2 to post-SP2 (P < .001). In normal infants, the mean RV EDVi was 50 ± 10 mL/m² (approximately half that of patients with HLHS), and the mean EF was 51 ± 3%. There was good interobserver agreement for EDVi, end-systolic volume indexed to body surface area, and EF.
Real-time three-dimensional echocardiography is a reproducible means for evaluating RV volumes and EFs in patients with HLHS. Indexed RV diastolic volume remains stable to slightly increased, and RV EF deteriorates as the first two stages of surgical palliation are accomplished. The findings of this study highlight the adverse physiology of HLHS, which deteriorates even among early survivors despite SP.
Risk factor analysis for second-stage palliation of single ventricle anatomy
2012, Annals of Thoracic Surgery
Single ventricle hearts can be surgically palliated by a series of operations culminating in the Fontan procedure, which establishes a total cavopulmonary connection. The second-stage procedure creates a physiologic connection between the superior vena cava and the pulmonary artery.
From 1998 to 2010, 557 patients with single ventricle heart disease underwent second-stage surgical palliation. This cohort was retrospectively analyzed to assess patient outcome by a number of anatomic, physiologic, and procedural factors. The analysis excluded patients undergoing hybrid first-stage procedures.
The median age at operation was 165 days (range, 59 days to 49 years). The most common anatomic subtypes were hypoplastic left heart syndrome (52%), tricuspid atresia (12%), unbalanced atrioventricular septal defect (10%), double inlet left ventricle (9%), or other (17%). Left ventricular hypoplasia was present in 70%. A hemi-Fontan procedure was done in 89%, and 11% received a bidirectional Glenn. Concomitant atrioventricular valve repair was necessary in 9%. Early mortality was 4.7%, and 5.9% died after discharge but before Fontan. No early or late deaths occurred in patients with tricuspid atresia and double inlet left ventricle. Multivariate analysis demonstrated ventricular dysfunction, atrioventricular valve regurgitation, and unbalanced atrioventricular septal defect were significant adverse risk factors for survival to Fontan.
Second-stage palliation can be performed at low risk for patients with left ventricular dominance, but significant risk remains for patients with left ventricular hypoplasia and unbalanced atrioventricular septal defect. Atrioventricular valve insufficiency is a persistent problem that has not been neutralized by repair strategies.

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Original articleChanges in right ventricular geometry and heart rate early after hemi-Fontan procedure

Abstract

Cardiol Clinic North Am

J Thorac Cardiovasc Surg

Chest

Am J Cardiol

J Thorac Cardiovasc Surg

Original article
Changes in right ventricular geometry and heart rate early after hemi-Fontan procedure