Ventricular Function in Patients With Transposition of the Great Arteries Operated With Arterial Switch

doi:10.1016/j.amjcard.2009.04.029

The American Journal of Cardiology

Volume 104, Issue 4, 15 August 2009, Pages 583-589

https://doi.org/10.1016/j.amjcard.2009.04.029 Get rights and content

The study aim was to investigate ventricular function at long-term follow-up in patients operated with arterial switch for transposition of the great arteries (TGAs). Although midterm results for anatomic correction of TGA are promising, there are reported minor alterations in left ventricular (LV) function possibly indicating myocardial dysfunction. Twenty-two patients with TGAs 12.4 ± 2.3 years old operated with arterial switch were studied by magnetic resonance imaging and echocardiography. Twenty-two age-matched healthy subjects served as controls. Myocardial deformation was described by longitudinal and circumferential shortening (measured as strain and strain rate) and ventricular torsion, measured by speckle-tracking echocardiography. Although standard measurements of global systolic LV function were normal in patients with TGAs, longitudinal shortening was decreased compared with controls. Longitudinal strain was decreased in all ventricular regions except the posterior wall and most pronounced in the apical segments. LV circumferential shortening was similar in the 2 groups. Also, in the right ventricular free wall patients displayed decreased longitudinal shortening in the mid and apical segment. Moreover, LV torsion was decreased in the TGA group. Although rotation was relatively homogenous at the apical and basal levels in controls, there was greater dispersion in rotation in the patient group, with basal rotation being greatest in the inferior wall and apical rotation being greatest in the anterior wall. In conclusion, there was slightly decreased longitudinal shortening in the 2 ventricles and decreased LV torsion in patients with TGAs, although standard measurements of global ventricular function were normal.

Section snippets

Methods

Twenty-two patients (7 female patients) with simple TGAs 12.4 ± 2.3 years of age operated on as infants with 1-stage arterial switch were identified from the hospital's database and examined by echocardiography, treadmill testing, and magnetic resonance imaging. Inclusion criteria were age >9 years and no additional lesions at birth other than small atrial or ventricular septal defect closed at the time of arterial switch operation by suture.

Twenty-two healthy volunteers (8 female subjects)

Results

All patients were asymptomatic and none had undergone further surgery since the initial operation. Time on extracorporeal circulation during the arterial switch procedure was 125 ± 32 minutes, and aortic cross clamp time was 46 ± 10 minutes. All were in sinus rhythm without conduction abnormalities and with no electrocardiographic changes at rest suggesting myocardial scar or during exercise suggesting ischemia. Spirometric examination showed a peak expiratory flow of 4.47 ± 1.07 L/s (80 ± 14%

Discussion

The present study demonstrates slightly decreased global longitudinal strain and LV torsion in arterial switch-operated patients with TGAs. Shortening was decreased in all ventricular wall regions except the posterior wall, and most pronounced at the apical level. This was not reflected by standard variables of global ventricular function, which were normal in patients. Diastolic function was also normal except for E′, which was slightly decreased. These findings suggest that assessment of

Acknowledgments

The authors thank Trond Vartdal, MD, for his contribution to the statistical analyses.

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Cited by (51)

Decreased cardiac reserve in asymptomatic patients after arterial switch operation for transposition of the great arteries
2023, International Journal of Cardiology
Exercise capacity is impaired in patients after arterial switch operation (ASO) for complete transposition of the great arteries. Maximal oxygen consumption is related with outcome.
This study assessed ventricular function by advanced echocardiography and cardiac magnetic resonance (CMR) imaging at rest and during exercise, to determine exercise capacity in ASO patients, and to correlate exercise capacity with ventricular function as potential early marker of subclinical impairment.
Forty-four patients (71% male, mean age 25 ± 4 years - range 18–40 years) were included during routine clinical follow-up. Assessment involved physical examination, 12‑lead ECG, echocardiography, and cardiopulmonary exercise test (CPET) (day 1). On day 2 CMR imaging at rest and during exercise was performed. Blood was sampled for biomarkers.
All patients reported New York Heart Association class I, the overall cohort had an impaired exercise capacity (80 ± 14% of predicted peak oxygen consumption). Fragmented QRS was present in 27%. Exercise CMR showed that 20% of patients had abnormal contractile reserve (CR) of the left ventricle (LV) and 25% had reduced CR of the right ventricle (RV). CR LV and CR RV were significantly associated with impaired exercise capacity. Pathological patterns on myocardial delayed enhancement and hinge point fibrosis were detected. Biomarkers were normal.
This study found that in some asymptomatic ASO patients electrical, LV and RV changes at rest, and signs of fibrosis are present. Maximal exercise capacity is impaired and seems to be linearly related to the CR of the LV and the RV. Therefore, exercise CMR might play a role in detecting subclinical deterioration of ASO patients.
Right Ventricular Systolic Dysfunction in Adults With Anatomic Repair of d-Transposition of Great Arteries
2023, American Journal of Cardiology
The purpose of this study was to assess the prevalence of right ventricular (RV) systolic dysfunction in adults with anatomic repair of dextro-transposition of great arteries (d-TGAs), and to determine its relation to clinical outcomes across multiple domains (functional status, peak oxygen consumption, N-terminal pro-brain natriuretic peptide, and heart failure hospitalization). Adults with anatomic repair for d-TGA and with echocardiographic images for strain analysis were divided into 2 groups: (1) d-TGA status after an arterial switch operation (d-TGA–ASO group) and (2) d-TGA status after a Rastelli operation (d-TGA–Rastelli group). RV systolic function was assessed using RV global longitudinal strain (RVGLS), and RV systolic dysfunction was defined as RVGLS >-18%. We identified 151 patients (median age 21 years [19 to 28]; d-TGA–ASO group 89 [59%], and d-TGA–Rastelli group 62 [41%]). The mean RVGLS was −22 ± 4%, and 47 patients (31%) had RV systolic dysfunction. The d-TGA–Rastelli group had lower (less negative) RVGLS than that of the d-TGA–ASO group (−19 ± 3% vs −25 ± 3%, p <0.001) and higher prevalence of RV systolic dysfunction (48% vs 19%, p <0.001). RVGLS (absolute value) was associated with peak oxygen consumption (r = 0.58, p <0.001; adjusted R² = 0.28), log–N-terminal pro-brain natriuretic peptide (r = −0.41, p = 0.004; adjusted R² = 0.21), New York Heart Association class III/IV (odds ratio 2.29, 1.56 to 3.19, p = 0.01), and heart failure hospitalization (hazard ratio 0.93, 0.88 to 0.98, p = 0.009). RV systolic dysfunction was common in adults with d-TGA and anatomic repair and was associated with clinical outcomes. Longitudinal studies are required to determine the risk factors for progressive RV systolic dysfunction and to identify strategies for preventing RV systolic dysfunction in this population.
Normal Left Ventricular Systolic and Diastolic Strain Rate Values in Children Derived from Two-Dimensional Speckle-Tracking Echocardiography
2021, Journal of the American Society of Echocardiography
Strain rate (SR) parameters derived from two-dimensional speckle-tracking echocardiography have prognostic value in children with heart disease. Routine use is hindered by a lack of normative data. The aim of this study was to determine reference values and Z scores for left ventricular systolic and diastolic SR in a large cohort of healthy children.
Echocardiograms from 577 subjects ≤18 years of age (mean age, 9.6 ± 5.6 years; range, 1 day to 18.0 years; 46% female) with structurally and functionally normal hearts were retrospectively included. Left ventricular longitudinal and circumferential systolic and early and late diastolic SR were measured using two-dimensional speckle-tracking echocardiography from the apical four-chamber and short-axis mid-papillary views. Associations with age and body surface area were assessed using Spearman correlation and generalized additive modeling. The relationship between systolic SR and wall stress (afterload) was examined. Analyses were conducted with and without correction for heart rate. Multivariable linear regression modeling was used to identify independent factors associated with the SR parameters. Z score equations were derived from a selected best-fit parametric model.
All SR parameters differed significantly by age group. The magnitude of all SR values decreased with increasing age and body surface area. Systolic SR magnitude was inversely related to wall stress in children ≤7 years of age but not did not vary significantly in the older age groups. All relationships were maintained after heart rate correction. SR measurements had very good or excellent agreement.
Longitudinal and circumferential systolic and diastolic SR parameters are presented from a large cohort of healthy children using two-dimensional speckle-tracking echocardiography from the Philips platform. SR values differ significantly by age and body surface area. These results suggest that the myocardium becomes less sensitive to afterload with maturity. Z score equations based on age are presented, which should promote further clinical and research use.
Time course and predictors for neoaortic root dilatation and neoaortic valve regurgitation during adult life after arterial switch operation
2021, Revista Espanola de Cardiologia
Hay pocos datos sobre la evolución en adultos de la dilatación de la raíz neoaórtica (RAO) y la insuficiencia valvular neoaórtica (IA) tras la cirugía de switch arterial (SA) en la transposición de grandes arterias.
Análisis retrospectivo de 152 pacientes con transposición de grandes arterias, mayores de 15 años, intervenidos mediante SA y seguidos durante 4,9 ± 3,3 años en 2 centros de referencia. Se analizaron los cambios de diámetro de la RAO ajustados a superficie corporal y la progresión a grado moderado/grave de la IA con ecocardiografías seriadas. Se realizó un modelo de regresión de Cox para identificar factores predictores de progresión de la IA.
Inicialmente, 4 pacientes (2,6%) presentaban IA grave (3 habían precisado cirugía valvular) y 9 (5,9%) moderada. La RAO basal media era 20,05 ± 2,4 mm/m², y al final del seguimiento, 20,73 ± 2,8 mm/m² (p < 0,001), con un crecimiento medio de 0,14 (IC95%, 0,07-0,2) mm/m²/año. La IA progresó en 20 (13,5%) y 6 (4%) fueron intervenidos. La progresión de IA se asoció con válvula bicúspide, IA inicial, dilatación de la RAO inicial y crecimiento de la RAO. La válvula bicúspide (HR = 3,3; IC95%, 1,1-15,2; p = 0,037), la IA inicial (HR = 5,9; IC95%, 1,6-59,2; p = 0,006) y el crecimiento de la RAO (HR = 4,1; IC95%, 2-13,5; p = 0,023) resultaron predictores independientes.
La dilatación de la RAO y la IA progresan en el adulto joven intervenido mediante SA. La válvula bicúspide, la IA basal y el crecimiento de la RAO son predictores de progresión de IA.
There are limited data on the long-term development of neoaortic root dilatation (NRD) and neoaortic valve regurgitation (AR) after arterial switch operation (ASO) for transposition of the great arteries during adult life.
We performed a retrospective longitudinal analysis of 152 patients older than 15 years who underwent ASO for transposition of the great arteries and who were followed-up for 4.9 ± 3.3 years in 2 referral centers. Sequential changes in body surface-adjusted aortic root dimensions and progression to moderate/severe AR were determined in patients with 2 or more echocardiographic examinations. Risk factors for dilatation were tested by Cox regression to identify predictors of AR progression.
At baseline, moderate AR was present in 9 patients (5.9%) and severe AR in 4 (2.6%), of whom 3 had required aortic valve surgery. Initially, the median neoaortic root dimension was 20.05 ± 2.4 mm/m², which increased significantly to 20.73 ± 2.8 mm/m² (P < .001) at the end of follow-up. The mean change over time was 0.14 mm/m²/y (95%CI, 0.07-0.2). Progressive AR was observed in 20 patients (13.5%) and 6 patients (4%) required aortic valve surgery. Progressive AR was associated with bicuspid valve, AR at baseline, NRD at baseline, and neoaortic root enlargement. Independent predictors were bicuspid valve (HR, 3.3; 95%CI, 1.1-15.2; P = .037), AR at baseline (HR, 5.9; 95%CI, 1.6-59.2; P = .006) and increase in NRD (HR, 4.1 95%CI, 2-13.5; P = .023).
In adult life, NRD and AR progress over time after ASO. Predictors of progressive AR are bicuspid valve, AR at baseline, and increase in NRD.
Gothic aortic arch and cardiac mechanics in young patients after arterial switch operation for d-transposition of the great arteries
2017, International Journal of Cardiology
In patients who have undergone arterial switch operation (ASO) for d-transposition of the great arteries a gothic aortic arch (GA) morphology has been found and it has been associated with abnormal aortic bio-elastic properties.
GA is frequent in ASO patients and may have an impact on cardiac mechanics. Our study aims were to assess 1- the occurrence of GA in a large sample of patients after ASO; 2- the association between GA and aortic bio-elastic properties; and 3- the impact of GA on left ventricular (LV) function using speckle tracking echocardiography (STE).
We studied one hundred and five asymptomatic patients, who have undergone first stage ASO for d-TGA, with normal left ventricular ejection fraction (LVEF ≥ 53%).
Forty-six (44%) patients showed a GA (mean age 11.5 ± 7.2 years, 26 males) while fifty-nine (56%) patients (mean age 9.6 ± 6.7 years, 37 males) did not present GA. The two groups were comparable for age, sex, BSA, and office blood pressure values. In group GA aortic root was significantly dilated (27.4 ± 7.5 mm vs. 21.2 ± 6.9 mm, p < 0.0001), aortic stiffness index (Group GA = 1.8 ± 1.2 vs. 1.4 ± 0.7, p = 0.025) was significantly increased, left atrial volume was larger (p = 0.0145), global longitudinal strain (Group GA = − 18.4 ± 2.5% vs. − 20.1 ± 3.3%, p = 0.012) and basal LV longitudinal strains (Group GA = − 16.9 ± 4.8% vs. − 20.4 ± 7.0%, p = 0.013) were significantly reduced.
After ASO the presence of a GA is associated with a significantly dilated aortic root, stiffer aortic wall, larger left atrial volume, and worse LV longitudinal systolic deformations, well known predictors of cardiovascular morbidity and mortality.
Two-dimensional right ventricular strain by speckle tracking for assessment of longitudinal right ventricular function after paediatric congenital heart disease surgery
2017, Archives of Cardiovascular Diseases
Right ventricular (RV) function is a prognostic marker of cardiac disease in children. Speckle tracking has been developed to assess RV longitudinal shortening, the dominant deformation during systole; little is known about its feasibility in children with congenital heart disease (CHD).
To evaluate the feasibility and reproducibility of RV two-dimensional (2D) strain assessed by speckle tracking in infants undergoing CHD surgery compared with conventional markers.
In this prospective single-centre study, RV peak systolic strain (RV-PSS) was measured using 2D speckle tracking in 37 consecutive children undergoing CHD surgery. Examinations were performed the day before surgery, a few hours after surgery and before discharge. Relationships with the z score of tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TA Sa) were assessed.
Median (interquartile range) age was 19 months (5–63); median weight was 9.2 kg (5.3–18.0). RV-PSS analysis was feasible in 92.9% (95% confidence interval [CI]: 86.0–97.1) of examinations. The coefficient of variation was 9.7% (95% CI: 7.4–11.9) for intraobserver variability and 15.1% (95% CI: 12.7–17.6) for interobserver variability. Correlations between RV-PSS and z score of TAPSE and TA Sa were strong (r = 0.71, P < 0.0001 and r = 0.70, P < 0.0001, respectively). RV-PSS was significantly reduced after surgery compared with baseline (–10.5 ± 2.9% vs. –19.5 ± 4.8%; P < 0.0001) and at discharge (–13.5 ± 4.0% vs. –19.5 ± 4.8%; P < 0.0001). Similar evolutions were observed with TAPSE and TA Sa (both P < 0.0001).
RV longitudinal strain by speckle tracking is a feasible and reproducible method of assessing perioperative evolution of RV function in children with CHD.
La fonction ventriculaire droite (VD) est un déterminant pronostique des cardiopathies de l’enfant. L’analyse par speckle tracking permet d’évaluer le raccourcissement longitudinal des fibres VD qui correspond à la composante systolique dominante. La faisabilité de ce nouveau paramètre a été peu étudiée en cardiopédiatrie.
Nous avons évalué la faisabilité et la reproductibilité du strain VD par speckle tracking chez des enfants opérés d’une cardiopathie congénitale.
Le pic systolique de strain (PSS) de la paroi libre du VD a été mesuré prospectivement par speckle tracking chez 37 enfants inclus consécutivement. Trois échocardiographies ont été réalisées : le jour précédant la chirurgie, quelques heures après la chirurgie et en fin d’hospitalisation. Le PSS a été comparée à des marqueurs de fonction systolique conventionnels.
L’âge médian (ITQ) était de 19 mois (5–63) avec un poids médian de 9,2 kg (5,3–18,0). L’analyse du PSS-VD était possible pour 92,9 % (IC 95 % : 86,0–97,1) des acquisitions. Le coefficient de variation intra-observateur était de 9,7 % (IC 95 % : 7,4–11,9) et inter-observateur de 15,1 % (IC 95 % : 12,7–17,6). Les corrélations entre le PSS-VD, le z score du TAPSE et l’Onde S tricuspide étaient bonnes (r = 0,71, p < 0,0001 ; r = 0,70, p < 0,0001). En postopératoire, le PSS-VD était diminué par rapport à l’échocardiographie préopératoire (–10,5 ± 2,9 % vs –19,5 ± 4,8 % ; p < 0,0001) ainsi qu’en fin d’hospitalisation (–13,5 ± 4,0 % vs –19,5 ± 4,8 % ; p < 0,0001).
La mesure du strain longitudinal VD par speckle tracking est faisable et reproductible pour évaluer l’évolution de la fonction systolique VD après chirurgie cardiaque pédiatrique.

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: Dr. Pettersen was the recipient of a fellowship from the Norwegian Research Council, Oslo, Norway.

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Congenital heart diseaseVentricular Function in Patients With Transposition of the Great Arteries Operated With Arterial Switch

Section snippets

Methods

Results

Discussion

Acknowledgments

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Results of the arterial switch operation for transposition of the great arteries with ventricular septal defectSurgical considerations and midterm follow-up data

Circulation

Midterm results after the arterial switch operation for transposition of the great arteries with intact ventricular septum: clinical, hemodynamic, echocardiographic, and electrophysiologic data

Circulation

Neo-aortic valvar function after the arterial switch

Cardiol Young

Myocardial blood flow and flow reserve after coronary reimplantation in patients after arterial switch and Ross operation

Circulation

Congenital heart disease
Ventricular Function in Patients With Transposition of the Great Arteries Operated With Arterial Switch