Congenital heart disease
Effects of Morphologic Left Ventricular Pressure on Right Ventricular Geometry and Tricuspid Valve Regurgitation in Patients With Congenitally Corrected Transposition of the Great Arteries

https://doi.org/10.1016/j.amjcard.2009.10.066Get rights and content

Congenitally corrected transposition of the great arteries (CCTGA) is associated with tricuspid regurgitation (TR), which has been postulated to arise from the effect of ventricular septal position on the attachments of the tricuspid valve. This study was performed to determine the effect of left ventricular (LV) pressure on right ventricular (RV) and LV geometry and the degree of TR. Serial echocardiograms were reviewed from, 30 patients with CCTGA who underwent pulmonary artery banding to train the morphologic left ventricle (n = 14) or left ventricle–to–pulmonary artery conduit placement and ventricular septal defect closure in conjunction with physiologic repair (n = 16). The degree of TR, the LV/RV pressure ratio, RV and LV sphericity indexes, and tricuspid valve tethering distance and coaptation length were analyzed. After pulmonary artery banding, an increase in LV systolic pressure to ≥2/3 systemic resulted in a decrease in TR from severe to moderate (p = 0.02). The percentage of patients with severe TR decreased from 64% to 18% (p = 0.06). The RV sphericity index decreased (p = 0.05), and the LV sphericity index increased (p = 0.02). After left ventricle–to–pulmonary artery conduit placement, a decrease in LV pressure to ≤1/2 systemic resulted in an increase in TR from none to mild (p = 0.003). In conclusion, these data indicate that LV pressure in patients with CCTGA affects the degree of TR and that septal shift caused by changes in LV and RV pressure is an important mechanism.

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Methods

Review of the University of Michigan Health System's Division of Pediatric Cardiology echocardiographic database identified all patients with CCTGA who underwent surgical interventions that were expected to alter the LV/RV pressure ratio while leaving the right ventricle as the systemic ventricle. Patients requiring single-ventricle palliation were excluded. We examined 2 groups of patients. Those in group 1 underwent PA banding to increase LV pressure in preparation for eventual double-switch

Results

Fourteen patients with CCTGA underwent PA banding placement for retraining of the morphologic left ventricle (group 1). The median age in this group was 1.1 years (range 0 to 12.1). Associated lesions included small ventricular septal defects; mild pulmonary stenosis; thickened, apically displaced tricuspid valves; and complete heart block, with 2 patients requiring pacemakers preoperatively and 2 additional patients requiring 1 postoperatively (Table 1). The median time interval between

Discussion

In this study, we evaluated the effect of procedures that changed predominately the LV pressure on the RV geometry, tricuspid valve geometry and the degree of TR. Patients who underwent banding of the pulmonary artery with increases in LV pressure to ≥2/3 RV pressure developed less spherical right ventricles and more spherical left ventricles with decreased TR. Because no patients in the PA banding group had substantial left ventricle–to–right ventricle shunts, PA banding should not have

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