Clinical Investigation
Ventricular Dyssynchrony in Children
QRS Duration and Mechanical Dyssynchrony Correlations with Right Ventricular Function after Fontan Procedure

https://doi.org/10.1016/j.echo.2012.10.018Get rights and content

Background

In studies of adult patients, increased QRS duration and mechanical dyssynchrony have been associated with decreased ventricular function. The aim of this study was to test the hypothesis that similar findings would be present in a population of patients with hypoplastic left heart syndrome (HLHS) after the Fontan procedure.

Methods

A retrospective cross-sectional study was conducted. All patients with HLHS after the Fontan procedure were eligible. QRS duration was measured using 12-lead electrocardiography. Echocardiographic measurements of mechanical dyssynchrony included Doppler tissue imaging (DTI) QRS to onset of s′ wave difference between the left ventricle and the right ventricle, time to peak strain, time to peak systolic strain rate (SRs), the standard deviation of time to peak strain rate (modified Yu strain), and the standard deviation of time to peak SRs (modified Yu SRs). Right ventricular (RV) functional measurements included DTI s′ wave, DTI RV myocardial performance index, global strain, global SRs, and RV fractional area change. Pearson's correlations were performed between the variables.

Results

Thirty-one echocardiographic studies were performed on 26 patients. The median age was 5.3 years (range, 2.5–15.4 years). QRS duration was correlated significantly with global SRs (r = 0.42). Time to peak SRs was correlated significantly with DTI s′ wave (r = −0.48) and global SRs (r = 0.37). Modified Yu SRs was correlated significantly with global strain (r = 0.35) and RV fractional area change (r = −0.35).

Conclusions

Both QRS duration and mechanical dyssynchrony were correlated with RV function, albeit weakly. The clinical significance of these findings is intriguing, but only larger studies will determine if these measurements are reliable in guiding treatment options for this complex patient population.

Section snippets

Methods

The institutional review board approved this cross-sectional, retrospective study. All patients with HLHS who had undergone the Fontan procedure were included. Patients also needed to have adequate echocardiographic images with frame rates of 60 to 110 frames/sec performed obtained using a Vivid I or Vivid 7 machine (GE Healthcare, Wauwatosa, WI). An electrocardiogram obtained within 3 months of the echocardiogram was also required. The offline echocardiographic database was searched for these

Results

A total of 30 patients with HLHS were identified, with 35 studies performed. Four studies were excluded, one because of an atrial arrhythmia, one because of the lack of an electrocardiographic tracing at the time of imaging, and two because of inadequate imaging and/or speckle-tracking analysis. A total of 31 studies from 26 patients were thus available for analysis.

The median age of the patients at the time of echocardiography was 5.3 years (range, 2.5–15.4 years), the median time from Fontan

Discussion

Increased electrical dyssynchrony measured by QRS duration and mechanical dyssynchrony measured via various echocardiographic techniques have been shown in the adult population to correlate with worse left ventricular and RV function.8, 9, 23 In the pediatric population with biventricular physiology, narrowing of the QRS duration via CRT has been noted to correlate with improved function.10, 11, 12 Increased QRS duration and mechanical dyssynchrony have been reported in patients with single RV

Conclusions

Both QRS duration and mechanical dyssynchrony measurements were correlated with RV function in patients with single right ventricles, albeit weakly. The clinical significance of these findings is unknown, and only larger studies will determine if these measurements are beneficial or not in deciding treatment options for this complex patient population.

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