Quantitative assessment of systolic and diastolic ventricular function with tissue Doppler imaging after Fontan type of operation

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Abstract

Background

There is evidence that “inappropriate hypertrophy” of the single left ventricle, which occurs as a result of acute preload reduction, leads to adverse consequences on ventricular function. However, a systematic study of the capability of tissue Doppler imaging (TDI) to assess systolic and diastolic ventricular functions after the Fontan procedure is still missing.

Methods

Twenty-four postoperative patients aged 12–33 years were prospectively evaluated with two-dimensional echocardiography equipped with TDI capabilities. Nineteen age-matched normal subjects were selected as controls. Good-quality echoes for the measurement of ejection fractions were available in 21 patients. Ten patients (group 1) had systolic dysfunction (ejection fraction <50%), and 11 patients (group 2) had normal systolic function. Peak systolic and diastolic wall velocities were acquired from the two-chamber view in the myocardia and mitral annulus.

Results

Compared with controls, the Fontan patients had a significantly reduced peak systolic velocity at wall and annulus sites. A linear correlation existed between ejection fraction and systolic myocardial velocity from the annular sites. Group 1 patients had lower wall velocities and lower annulus velocities both in systole and diastole. Group 2 patients had preserved systolic velocities but decreased regional and annular early diastolic velocities, suggesting impaired filling. Multiple correlation analysis showed a relation between peak early diastolic mitral velocity and ventricular ejection fraction, mean mitral annular motion at systole, mass/volume ratio, and the number of years post Fontan revision.

Conclusions

Myocardial velocities recorded after the Fontan operation give insight into systolic and diastolic ventricular functions. The peak systolic mitral annular velocity correlated well with the ventricular ejection fraction. The peak early diastolic velocity and the ratio between the early and late diastolic mitral annular velocity are reduced and reflect diastolic dysfunction even in the presence of normal systolic ejection fraction.

Introduction

Fontan and Baudet [1] first reported a successful total right-sided cardiac bypass in patients with a single functional ventricle in 1971. Since then, advances in operative technique and postoperative management have been accompanied by an improvement in early survival [2], [3], [4]. As more patients survive the operation and as the duration of follow-up increases, physicians are becoming increasingly aware of a continued risk of late failure of the Fontan circulation. A progressive deterioration in functional status may occur and the absence of other predicting risk factors suggests that the Fontan state itself or the transition to it is the risk factor for such decline. There is evidence that the “inappropriate hypertrophy” of the left ventricle, which occurs as a result of acute preload reduction, leads to adverse consequences manifested by prolonged isovolumic relaxation time, reduction in early rapid filling, abnormal wall motion, and intracavitary flow during isovolumic relaxation [5], [6], [7], [8], [9], [10], [11].

Tissue Doppler imaging (TDI) is a new echocardiographic technique that records myocardial velocities during the cardiac cycle [12], [13], [14]. Both the systolic and diastolic velocities can be recorded quantitatively by TDI and thereby provide a new way of assessing ventricular function. The conventional echocardiographic methods for assessing cardiac function are based on endocardial movement and/or wall thickening and have several limitations, especially in cases of unsatisfactory echo quality. Assessment of cardiac function by TDI may be more sensitive than traditional methods. Previous studies from our laboratory and others have described this technique as a feasible method of assessing systolic and diastolic left ventricular function [15], [16], [17], [18], [19]. However, a systematic study on the capability of TDI to assess systolic and diastolic ventricular function after the Fontan operation is still missing.

The aim of the present study is to evaluate the effects of the Fontan procedure on the TDI velocity profile of the left ventricle during systole and diastole and to compare them with standard echocardiographic indexes.

Section snippets

Population

Twenty-four patients (15 males and 9 females) who underwent the Fontan procedure at mean (S.D.) 7.3 (4.1) (range 1.8–13.7) years old were studied at 7.4 [2], [8] years after the operation. Ten of these had double inlet ventricle, 13 had tricuspid atresia (with concordant ventriculo-arterial connection in 11 and discordant connection in 2), and 1 had a more complex lesion (including atresia of an atrioventricular valve other than typical tricuspid atresia). Total cavopulmonary anastomosis was

Results

The results are summarized in Table 1, Table 2, Table 3, Table 4, Table 5. The intraobserver error was low for wall velocities (4.3±3.9%, 5.7±4.6%, and 6.4±4.9% for peak systolic, peak early diastolic, and peak late diastolic velocities, respectively) and annular velocities (4.2±3.6%, 5.9±4.3%, and 6.2±5.1% for peak systolic, peak early diastolic, and peak late diastolic velocities, respectively). The interobserver error was also low for wall velocities (4.9±4.1%, 6.1±5.6%, and 6.7±6.1%,

Discussion

This study shows changes in systolic tissue Doppler indexes late after the Fontan procedure correlating with reduction in left ventricular ejection fraction and changes in diastolic tissue Doppler indexes, consistent with persisting abnormalities of ventricular filling in the presence of normal systolic ejection fraction.

Conclusions

Myocardial velocities recorded after the Fontan operation give insight into systolic and diastolic ventricular function. The peak systolic mitral annular velocity correlated well with the ventricular ejection fraction. The peak early diastolic velocity and the ratio between the early and late diastolic mitral annular velocity are reduced and reflect diastolic dysfunction even in the presence of normal systolic ejection fraction. Thus, quantification of the myocardial velocity by TDI opens up a

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