doi: 10.1161/01.CIR.0000156455.52299.82
(Circulation. 2005;111:e112.)
© 2005 American Heart Association, Inc.
Correspondence |
Letter Regarding Article by Frigiola et al, "Pulmonary Regurgitation Is an Important Determinant of Right Ventricular Contractile Dysfunction in Patients With Surgically Repaired Tetralogy of Fallot"
Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
It was with great interest that we read the paper by Frigiola et al,1 who reported on the usefulness of myocardial acceleration during isovolumetric contraction, a Doppler-based index, as a relatively load-independent parameter for right ventricular function. The authors found that pulmonary regurgitation exerted a detrimental effect on the contractile function of the right ventricle, whereas previous reports failed to demonstrate that pulmonary regurgitation had a direct effect on systolic right ventricular function, probably resulting from the load-dependent nature of ejection fraction obtained with cardiovascular magnetic resonance (CMR).2,3
Two questions arise: How is isovolumetric contraction influenced by severe right ventricular dilatation or the presence of right ventricular outflow tract aneurysms? How far does the right ventricle dilate before irreversible contractile dysfunction develops? It currently is believed that right ventricular dilatation and the presence of a right ventricular outflow tract aneurysm are important factors in identifying the clinical status of patients with corrected tetralogy of Fallot in the presence of pulmonary regurgitation. This information cannot be obtained with transthoracic echocardiography because of the well-known limitations of this imaging technology in visualizing the entire right ventricle, especially the right ventricular outflow tract. Therefore, we would like to stress the importance of CMR in the (preoperative) evaluation of patients after correction for tetralogy of Fallot. CMR provides additional information before possible surgery by visualizing the pulmonary tree with magnetic resonance angiography and by accurately determining the degree of pulmonary regurgitation with velocity mapping. We agree with the authors that the timing of pulmonary valve replacement can be facilitated with a relatively load-independent marker for right ventricular contractile dysfunction, and we look forward to future research on this issue.
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 Top References References |
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1. Frigiola A, Redington AN, Cullen S, Vogel M. Pulmonary regurgitation is an important determinant of right ventricular contractile dysfunction in patients with surgically repaired tetralogy of Fallot. Circulation. 2004; 110 (suppl II): II-153–II-157.[Medline] [Order article via Infotrieve]
2. Roest AA, Helbing WA, Kunz P, van den Aardweg JG, Lamb HJ, Vliegen HW, van der Wall EE, de Roos A. Exercise MR imaging in the assessment of pulmonary regurgitation and biventricular function in patients after tetralogy of Fallot repair. Radiology. 2002; 223: 204–211.
3. Davlouros PA, Kilner PJ, Hornung TS, Li W, Francis JM, Moon JC, Smith GC, Tat T, Pennell DJ, Gatzoulis MA. Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction. J Am Coll Cardiol. 2002; 40: 2044–2052.
Response
Grown up Congenital Heart Unit, The Heart Hospital, London, UK
The Hospital for Sick Children, Toronto, Canada
Kinderherzpraxis München, Munich, Germany
We have read the comments by Oosterhof and colleagues about our article in Circulation1 with interest. We are, of course, aware of the utility of cardiovascular magnetic resonance (CMR) in the evaluation of patients with tetralogy of Fallot. Although CMR is well suited to assess right ventricular volumes and the anatomy of the right ventricular outflow tract,2 together with the central and peripheral pulmonary arteries, myocardial (tissue) Doppler echocardiography (MDE) remains the most applicable method to assess global3 and regional4 ventricular function. Indeed, MDE increasingly is being used as a bedside tool to detect early myocardial dysfunction and dyssynchrony in adults with acquired and congenital heart disease.5 Our study was a cross-sectional one, and more studies are clearly needed; however, MDE, CMR, or a combination of methods may be used to identify patients with tetralogy of Fallot and pulmonary regurgitation who may potentially benefit from valve replacement—in particular, those in whom the right ventricular dysfunction is reversible.6 The latter may be difficult to predict with load-dependent indices such as ventricular volumes and ejection fraction, especially in patients who have significant tricuspid regurgitation. Future studies should be designed to address the question of whether a threshold exists for regional or global dysfunction to predict reverse remodeling, which is an inconsistent result of pulmonary valve replacement in these patients.6
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TopReferencesReferences |
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1. Frigiola A, Redington AN, Cullen S, Vogel M. Pulmonary regurgitation is an important determinant of right ventricular contractile dysfunction in patients with surgically repaired tetralogy of Fallot. Circulation. 2004; 110 (suppl II): II-153–II-157.[Medline] [Order article via Infotrieve]
2. Roest AA, Helbing WA, Kunz P, van der Aardweg JG, Lamb HJ, Vliegen HW, van der Wall EE, de Roos A. Exercise MR imaging in the assessment of pulmonary regurgitation and biventricular function in patients after tetralogy of Fallot repair. Radiology. 2002; 223: 204–211.
3. Vogel M, Sponring J, Cullen S, Deanfield JE, Redington AN. Regional wall motion and abnormalities of depolarization and repolarization in patients after surgical repair of tetralogy of Fallot. Circulation. 2001; 103: 1669–1673.
4. Vogel M, Derrick G, Cullen S, White PA, Deanfield J, Redington AN. Systemic ventricular function in transposition after Mustard/Senning repair: a tissue Doppler and conductance catheter study. J Am Coll Cardiol. 2004; 43: 100–106.
5. Vogel M. Anderson LJ, Holden S, Deanfield JE, Pennell DJ, Walker JM. Tissue Doppler echocardiography in patients with thalassaemia detects early myocardial dysfunction related to myocardial iron overload. Eur Heart J. 2003; 24: 113–119.
6. Therrien J, Siu SC, McLaughlin PR, Liu PP, Williams WG, Webb G. Pulmonary valve replacement in adults later after repair of tetralogy of Fallot: are we operating too late? J Am Coll Cardiol. 2000; 36: 1670–1675.
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