Clinical Investigation
Congenital Heart Disease
The Assessment of Atrial Function in Single Ventricle Hearts from Birth to Fontan: A Speckle-Tracking Study by Using Strain and Strain Rate

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Background

Single ventricle (SV) exercise performance is impaired and limited by reduced ventricular preload reserve. The atrium modulates ventricular filling, and enhancement of atrial compliance can increase cardiac performance. We aimed to study atrial mechanics in SV hearts across staged surgical palliation compared with healthy children by using novel speckle-tracking echocardiography techniques.

Methods

A cross-sectional study of 81 patients with SV (1 day to 6.5 years) at 4 stages of surgical palliation (presurgery, 22; prebidirectional cavopulmonary anastomosis, 23; pre-Fontan, 22; post-Fontan, 14). The dominant atrium was assessed with speckle-tracking echocardiography for active (εact), conduit (εcon), and reservoir (εres) strain; strain rate (SR); and εactres ratio before each stage of surgical palliation. Findings were compared with the left atrium of 51 healthy children (1 day to 5.5 years).

Results

Single ventricle atrial size was increased (P < .01), and atrial εres was decreased (P < .01) compared with healthy controls. SV atrial εcon (P < .01) and SRcon (P < .0001) was decreased, increased εact persisted (P < .05), and εactres was increased (P < .001) between surgical stages. Although the expected maturational trend of increasing εcon, decreasing εact, and εactres occurred in SV, they lagged behind healthy maturational changes (P < .0001).

Conclusion

Single ventricle atrium is dilated, has deceased compliance, decreased early diastolic emptying, and increased reliance on active atrial contraction for ventricular filling. This deviates from normal early childhood maturational changes and appears to parallel those of an atrium facing early ventricular diastolic dysfunction.

Section snippets

Population

This was a cross-sectional study, between 2007 and 2010, of patients with SV physiology at the Stollery Children's Hospital, Edmonton, Alberta, Canada, and the Children's Hospital and Medical Center, Omaha, Nebraska. Patients with functionally single left or right ventricle hearts in sinus rhythm were prospectively recruited at a single time point at any 4 surgical stages: (1) before their first procedure (presurgery): i.e., Norwood-Sano for hypoplastic left ventricle and modified

Study Population

Eighty-one patients with functionally single right (n = 55) or left (n = 26) ventricles were prospectively recruited at 4 surgical stages: (1) presurgery, 22; (2) pre-BCPA, 23; (3) pre-Fontan, 22; and (4) post-Fontan, 14. Of 51 controls, there were 14 neonates for presurgery comparison (Norm I), 13 infants for pre-BCPA (Norm II), 12 children for pre-Fontan (Norm III), and 12 children for post-Fontan (Norm IV). Eight patients were excluded secondary to inadequate deformation tracking of the

Discussion

The main findings of this study were that the SV atrium increased size, reduced reservoir function and reduced conduit function, and an increased reliance on atrial active function for ventricular filling. These differences are present before any surgical intervention and remain abnormal at each stage of surgical palliation. The SV atrial mechanics deviate significantly from expected normal early childhood maturational changes and appear to parallel those of an atrium that is facing early

Conclusion

The atrium in SV hearts is dilated, has deceased atrial compliance, decreased early diastolic emptying, and an increased reliance on active atrial contraction for ventricular filling. These changes are present before any surgical intervention and remain abnormal across the staged surgical palliation. The atrial mechanics in SV hearts deviate significantly from expected normal early childhood maturational changes and appear to parallel those of atrium facing early ventricular diastolic

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