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PubMed1999

How to manage secondary pulmonary hypertension.

Establishing an underlying cause and treatment plan for patients with pulmonary hypertension presents a significant challenge to practicing physicians. Doppler echocardiography is a simple, cost-effective tool for detecting pulmonary hypertension and evaluating right ventricular function. Nonspecific therapy (use of digoxin and diuretics, anticoagulation) for pulmonary hypertension and right ventricular failure achieves a degree of symptomatic improvement and should be considered in patients with moderate to severe disease. CTEPH should be considered in patients with dyspnea. Because severs forms of pulmonary hypertension usually are not discovered until late in the disease course, a high level of suspicion is required when evaluating symptoms and risk factors consistent with pulmonary vascular disease. Pulmonary hypertension is classified as idiopathic, or primary, when no secondary cause can be identified. Primary pulmonary hypertension is a devastating disease that largely affects young women. Significant advances in treatment have been made and will be discussed in detail in part 2 of this article.

Chronic Disease↗
PubMed1993

[Emergency aorto-coronary bypass surgery for patients with right ventricular infarction].

Infarction of the right ventricle occurs with acute inferior myocardial infarction and results in a unique syndrome, characterized by distended neck vein, hypotension, heart block and spontaneous recovery in right ventricular function with time. We performed aorto-coronary surgery for four patients with right ventricular infarction. Three of them had emergency surgery. Surgical indications were refractory angina pectoris in two and cardiogenic shock in one. Postoperative courses in these patients were stormy and two died. Low output syndrome rarely improved with volume load alone and required inotropic and vasoactive drugs. Antiarrhythmic therapy including artificial pacing was especially important in keeping IABP support effectively. Remaining case, on the other hand, were conservatively supported by IABP and drug therapy through the first two weeks after infarction and then operation was done for unstable angina. Postoperative course in this patient was uneventful. In conclusion, delayed surgical intervention may be considered in patients with right ventricular infarction if their hemodynamic condition in the early stage of infarction can be conservatively managed.

Aged↗
PubMed2003

Comparison of permanent left ventricular and biventricular pacing in patients with heart failure and chronic atrial fibrillation: a prospective hemodynamic study.

BACKGROUND: Left ventricular pacing (LVP) and biventricular pacing (BVP) have been proposed as treatments for patients with advanced heart failure complicated by discoordinate contraction due to intraventricular conduction delay. For patients in sinus rhythm, BVP works in part by modulating the electronic atrial-ventricular time delay and thus optimizing contractile synchrony, the contribution of atrial systole, and reducing mitral regurgitation. However, little is known of the mechanisms of BVP in heart failure patients with drug-resistant chronic atrial fibrillation. HYPOTHESIS AND METHODS: LVP differs from BVP because hemodynamic and clinical improvement occurs in association with prolongation rather than shortening of the QRS duration. We sought to determine if LVP or BVP improves mechanical synchronization in the presence of atrial fibrillation. Thirteen patients with chronic atrial fibrillation, severe heart failure and QRS >or=140 ms received (after His bundle ablation) a pacemaker providing both LVP and BVP. The mean age was 62 +/- 6 years and left ventricular ejection fraction was 24 +/- 8%. After a baseline phase of one month with right ventricular pacing, all patients underwent in random order 2 phases of 2 months (LVP and BVP). At the end of each phase, an echocardiogram, a hemodynamic analysis at rest and during a 6-minute walking test and a cardio-pulmonary exercise test were performed. RESULTS: LVP and BVP provided similar performances at rest (p = ns). The 6-minute walking test revealed similar performances in both pacing modes but patients were significantly more symptomatic at the end of the test with LVP ( p = 0.035). The cardio-pulmonary exercise test showed higher performances with BVP (92 +/- 34 Watts) vs. LVP (77 +/- 23; p = 0.03). LVP was associated with significantly more premature ventricular complexes recorded during the 6 minute walking test (49 +/- 71) than BVP (10 +/- 23; p = 0.04). CONCLUSIONS: In this small series of patients with atrial fibrillation, congestive heart failure and a prolonged QRS duration, LVP and BVP provided similar hemodynamic effects at rest whereas BVP was associated with better hemodynamic effects during exercise and fewer premature ventricular complexes. Although the mechanisms for the observed differences are uncertain, it is possible that there is worsening of right ventricular function due to a rise in left-to-right electromechanical delay during exercise. Increased catecholamines release might contribute to the lower exercise tolerance and greater number of premature ventricular complexes recorded during exercise observed during LVP compared to BVP. RECOMMENDATIONS: Patients with atrial fibrillation, heart failure and QRS prolongation who are candidates for His-bundle ablation and cardiac resynchronization therapy may respond better to BVP rather than to LVP.

Atrial Fibrillation↗
PubMed2002

Septation of the single ventricle: revisited.

BACKGROUND: Septation of a single ventricle into 2 functioning ventricles can provide an alternative to the Fontan operation. However, early experiences with septation reported unacceptable morbidity and mortality. The present study selected only those patients with large volume-overloaded hearts, 2 well-functioning atrioventricular valves, and an absence of severe outlet obstruction. Early and intermediate outcomes are evaluated. METHODS AND RESULTS: Between June 1990 and March 1999, 11 patients underwent septation in 1 or 2 stages. Diagnoses of the patients included double-inlet left ventricle in 9, double-inlet right ventricle in 1 patient, and indeterminate ventricle in 1 patient. Five had l-transposition and 3 had d-transposition of the great arteries. Six had septation as 1 stage, 5 as planned 2-stage operations (2/5 completed). The median age for septation in 1 stage was 2.1 years (range 4 months to 5.8 years); for 2 stages, the median age was 7.2 months (range 3 to 14 months). Median follow-up time was 2.3 years. Eight of 11 patients survived (73%), with 2 early deaths and 1 late death. Seven of the 8 survivors have undergone complete septation (5 as single stage, 2 as 2 stages). Complications included surgically induced complete atrioventricular block in 1 patient and significant residual ventricular septal defects in another. Qualitatively, left ventricular function by echocardiography is normal in all patients, whereas right ventricular function is mildly decreased in 1 patient. All patients are clinically well. CONCLUSION: The septation procedure for single ventricle hearts may be a reasonable alternative to the Fontan operation in selected patients.

Child↗
PubMed1997

Effects of long-term infusion of prostacyclin (epoprostenol) on echocardiographic measures of right ventricular structure and function in primary pulmonary hypertension. Primary Pulmonary Hypertension Study Group.

BACKGROUND: Right heart failure is an important cause of morbidity and mortality in primary pulmonary hypertension. In a recent prospective, randomized study of severely symptomatic patients, treatment with prostacyclin (epoprostenol) produced improvements in hemodynamics, quality of life, and survival. This article describes the echocardiographic characteristics of participants in this trial; the relationship of echocardiographic variables to hemodynamic parameters, exercise capacity, and quality of life; and the echocardiographic changes associated with prostacyclin therapy. METHODS AND RESULTS: The 81 patients enrolled in this multicenter trial were randomized to treatment with a long-term infusion of prostacyclin in addition to conventional therapy (n = 41) or conventional therapy alone (n = 40) for 12 weeks. Echocardiograms and assessments of hemodynamics, exercise capacity, and quality of life were performed before and after the treatment phase. On baseline evaluation, patients had marked right ventricular dilatation and dysfunction, abnormal septal curvature, and significant tricuspid regurgitation with a high regurgitant velocity. Pericardial effusions were common. More pronounced abnormalities in right heart structure and function were associated with higher pulmonary arterial and mean right atrial pressures, lower cardiac index, and impaired exercise capacity but had no predictable relationship to quality-of-life indicators. The 12-week infusion of prostacyclin had beneficial effects on right ventricular size, curvature of the interventricular septum, and maximal tricuspid regurgitant jet velocity. CONCLUSIONS: The echocardiographic manifestations of severe primary pulmonary hypertension reflect abnormalities in hemodynamics and exercise capacity. Prostacyclin has beneficial effects on right heart structure and function that may contribute to the clinical improvement and prolonged survival observed with this drug.

Adult↗
PubMed2003

ECG-gated 99mTc single-photon emission CT for assessment of right ventricular structure and function: is the information provided similar to echocardiography?

STUDY OBJECTIVE: (99m)Tc single-photon emission CT (SPECT) and ECG-gated SPECT can visualize well the right ventricle (RV) in most patients, but their utility for assessment of the RV has not been formally evaluated. We examined whether (99m)Tc SPECT/ECG-gated SPECT provide similar information to transthoracic two-dimensional Doppler echocardiography (2D-ECHO) regarding RV cavity size, wall thickness, and systolic function. DESIGN: Retrospective analysis. SETTING: A major university teaching hospital. PATIENTS: A consecutive series of 194 patients with good quality stress SPECT and 2D-ECHO studies performed within 1 day of each other and no significant interim cardiac events. MEASUREMENTS AND RESULTS: RV size and function were visually assessed by SPECT/ECG-gated SPECT and 2D-ECHO. RV wall thickness was visually assessed by SPECT and measured in mm in end-diastole by 2D-ECHO. Of 142 patients with normal RV cavity size by SPECT, 134 patients (94%) had normal RV cavity size by 2D-ECHO. However, of 52 patients with RV dilation by SPECT, only 9 patients (17%) had RV dilation by 2D-ECHO. A perfusion abnormality in the right coronary artery territory was significantly associated with RV dilation by SPECT (p < 0.005) and 2D-ECHO (p < 0.05). Among 150 patients with ECG-gated SPECT, only 2 patients had abnormal RV systolic function, as compared with 18 patients by 2D-ECHO. RV wall thickness measurements by SPECT and 2D-ECHO did not correlate. CONCLUSIONS: For normal interpretations regarding RV cavity size, wall thickness, and systolic function, there is good agreement between (99m)Tc stress SPECT/ECG-gated SPECT and 2D-ECHO. However, there is poor overall agreement between gated SPECT/ECG-gated SPECT and 2D-ECHO regarding the presence of RV dilation, hypertrophy, and systolic dysfunction.

Echocardiography, Doppler↗
PubMed2002

Immunohistologic evidence of myocardial disease in apparently healthy relatives of patients with dilated cardiomyopathy.

OBJECTIVES: This study investigated whether apparently healthy relatives of patients with idiopathic dilated cardiomyopathy (DCM) who have left ventricular enlargement (LVE) have biopsy evidence of underlying myocardial disease. BACKGROUND: Left ventricular enlargement with normal systolic function is common among asymptomatic relatives of patients with DCM. Although there is circumstantial evidence to suggest that LVE may be a marker of early DCM, its pathophysiologic significance remains uncertain. METHODS: Over six years, 767 asymptomatic relatives of 183 consecutive patients with DCM were evaluated: 37 (5%) had DCM and 104 (14%) had LVE (left ventricular end-diastolic dimension >112% predicted) with normal systolic function. Right ventricular biopsy was performed in 32 relatives with LVE, 14 patients with symptomatic DCM and 6 control subjects with normal ventricular function undergoing elective coronary artery bypass graft surgery. Histologic and immunohistochemical analyses, including quantitative double immunofluorescence, were performed for leukocyte markers (CD3 and CD68), intercellular adhesion molecule-1 (ICAM-1) and human leukocyte antigen class II antigens (DR and DQ). RESULTS: Histologic findings consistent with DCM were present in 50% of the patients with DCM, 25% of the relatives with LVE and 0% of the control subjects. The median CD3 count was 2.4/mm(2) in patients with DCM, 4/mm(2) in relatives with LVE and 0 in control subjects (p = 0.04). Using a threshold of >7 cells/mm(2), 21% of patients with DCM and 25% of relatives with LVE were CD3-positive (p = 0.01). Quantitative analysis demonstrated DR expression on 55.8+/-22.8%, 63.5+/-18.8% and 30.9+/-15.7% of the endothelial surface in patients with DCM, relatives and control subjects, respectively (p = 0.003). Corresponding values for ICAM expression were 35.6+/-15.1%, 36.7+/-14.5% and 17.3+/-7.9% (p = 0.013). When combining inflammatory and histologic changes, 28 (86%) of LVE, 14 (100%) of DCM and no control biopsies were abnormal (p < 0.001). CONCLUSIONS: Most asymptomatic relatives of patients with DCM with LVE have histopathologic and immunopathologic findings similar to those of patients with established disease. Clinical identification and follow-up of such individuals are warranted to prevent presentation with advanced DCM and to enable assessment of interventions aimed at attenuating disease progression.

Adult↗
PubMed1999

Nitric oxide inhalation in the treatment of primary graft failure following heart transplantation.

BACKGROUND: Primary graft failure from right or left ventricular insufficiency remains a serious cause of early death following heart transplantation. Inhaled nitric oxide (NO) is a potent pulmonary vasodilator that could decrease pulmonary pressure and improve right ventricular function. METHODS: Two cases of early graft failure following orthotopic heart transplantation were treated with NO inhalation. The treatment consisted of inhalation of 20 ppm of NO, introduced 4 to 6 hours following transplantation, in 2 patients supported with high doses of inotropic agents and vasopressors in addition to the intra-aortic balloon pump. RESULTS: In the first and second cases, NO inhalation resulted in a decrease in pulmonary artery pressure, in a decrease in pulmonary vascular resistance and in an increase in cardiac index. In the second patient, systemic oxygenation improved markedly 30 minutes after initiation of NO. In the 2 patients, NO inhalation, mechanical ventilation and the intra-aortic balloon pump were weaned 4 days following transplantation. CONCLUSION: Primary graft failure from donor ischemic damage, reperfusion injury or pulmonary hypertension remains a serious complication. The use of an intra-aortic balloon pump, inotropic agents and of inhaled NO appears to offer the best support for recovery of donor heart function. Primary graft failure from right or left ventricular insufficiency remains a serious cause of early mortality following heart transplantation. Ischemic damage of donor heart, reperfusion injury or pulmonary hypertension are the main causes of early graft failure. Although the cause is multifactorial, treatment of primary organ failure remains difficult with dismal results. The objective of the present study was to review the result of 2 patients with donor right heart failure following heart transplantation treated with inhaled nitric oxide (NO).

Administration, Inhalation↗
PubMed1990

The pericardium exerts constraint on the right ventricle during cardiac surgery.

The right ventricle may be particularly susceptible to the effects of pericardial constraint. This study examined the effects of pericardiotomy on right ventricular function. Twenty-four anesthetized patients with coronary artery disease, but without evidence of pericardial pathology, were studied. Anesthesia consisted of fentanyl (100 micrograms.kg-1), diazepam, pancuronium, and 100% oxygen. The American Edwards REF-1 Cardiac Output Computer, rapid-response thermistor pulmonary arterial catheter, and a radial arterial catheter were used to measure hemodynamic variables. Baseline measurements were obtained with the sternum fully retracted. The measurements were then repeated following pericardiotomy by a midline incision. There were significant (P less than 0.05) changes in systolic arterial pressure (+4.5%), mean arterial pressure (+3.7%), systolic pulmonary arterial pressure (+11.8%), cardiac output (+9.1%), stroke volume (+6.9%), right ventricular end-diastolic volume (+7.6%), and right atrial pressure (-8.6%). In the current study, pericardiotomy augmented right ventricular diastolic filling and stroke volume, while the right atrial pressure decreased. These results support the concept of pericardial constraint.

Adult↗
PubMed2006

Long-term bosentan in chronic thromboembolic pulmonary hypertension.

BACKGROUND: There is no approved pharmacological treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not suitable for pulmonary endarterectomy (PEA). OBJECTIVE: The study investigates the effect of the dual endothelin receptor antagonist bosentan on exercise tolerance (6-min walking distance, 6MWD) and right ventricular function (Tei index) in patients with CTEPH over 24 months. METHODS: Twelve consecutive patients (5 males and 7 females) with CTEPH not eligible for PEA or following partial or complete failure of PEA were included in a non-randomized, open-label prospective study. All patients were WHO class III. They were included, if progressive pulmonary hypertension was diagnosed despite best supportive treatment. Bosentan was started at 62.5 mg b.i.d. and increased to the final dose of 125 mg b.i.d. RESULTS: 6MWD and the Tei index were assessed every 6 months. We observed a significant increase in 6MWD from 319 +/- 85.0 m at baseline to 391 +/- 76.9 m at 6 months and a significant decrease in the Tei index from 0.39 +/- 0.10 at baseline to 0.34 +/- 0.08 at 6 months. This improvement was maintained over 24 months (6 MWD: 381 +/- 101 m; Tei index: 0.31 +/- 0.03). Six patients exhibited an improvement in WHO class at 6, 12 and 18 months, 5 demonstrated improvement at the 24-month follow-up. The remainder were stable throughout the study period. CONCLUSION: This is the first study demonstrating a long-term beneficial effect of bosentan on exercise tolerance (6MWD) and right heart function (Tei index) in CTEPH.

Antihypertensive Agents↗
PubMed1997

Role of right ventricular and pulmonary functional abnormalities in limiting exercise capacity in adults with congenital heart disease.

This study evaluates right ventricular (RV) and pulmonary function during exercise in adults with congenital heart disease (CHD). Thirty-one patients with CHD involving the right side of the heart underwent symptom-limited bicycle exercise testing with simultaneous expired gas analysis and measurement of RV ejection fraction (EF). Twenty-one age-matched normal controls underwent the identical exercise protocol. Maximal oxygen consumption was lower in the CHD than in normal controls (19.5 +/- 6.4 vs 30.5 +/- 0.8 ml/kg/min, p = 0.0001 patients vs controls). Both heart rate (156 +/- 25 vs 171 +/- 13 beats/min, p = 0.01) and oxygen pulse (9.3 +/- 3.7 vs 12.3 +/- 3.7 ml/beat, p = 0.01), an indirect measure of stroke volume, were found to be lower in the CHD group at peak exercise. Pulmonary dysfunction was evidenced in the CHD group by decreased forced expiratory volume, forced vital capacity and maximum voluntary ventilation, and by a higher ventilation/expired carbon dioxide ratio at peak exercise (37.2 +/- 6.9 vs 33.0 +/- 5.4, p = 0.02), suggesting an increase in dead space ventilation. Maximal oxygen consumption was lower in patients whose RVEF decreased with exercise (17.6 +/- 5.4 vs 22.8 +/- 6.4 ml/kg/min, p = 0.03 "decrease RVEF" group vs "increase RVEF" group). Maximal oxygen consumption correlated with the change in RVEF only in the group whose RVEF decreased with exercise (r = 0.5, p = 0.03). In the group that had increased RVEF with exercise, maximal oxygen consumption correlated with forced expiratory volume (r = 0.7, p = 0.02). Thus, adults with CHD have a reduced functional capacity compared with normal controls. This phenomenon appears to be associated with both RV and pulmonary abnormalities.

Adult↗
PubMed2003

New parameters in identification of right ventricular myocardial infarction and proximal right coronary artery lesion.

OBJECTIVE: The diagnosis of right ventricular myocardial infarction (RVMI) accompanied by acute inferior myocardial infarction (MI) is still a problem that we encounter. This study was designed to find out the usefulness both of peak myocardial systolic velocity (Sm) and of the myocardial performance index (MPI) of the right ventricle measured by pulsed-wave tissue Doppler imaging (TDI) in assessing right ventricular function. METHODS: Sixty patients who experienced a first acute inferior MI (mean [+/- SD] age, 57 +/- 9 years) were prospectively assessed. An ST-segment elevation of >or= 0.1 mV in V(4)-V(6)R lead derivations was defined as an RVMI. From the echocardiographic apical four-chamber view, the Sm, the peak early diastolic velocity, peak late diastolic velocity, the ejection time, the isovolumetric relaxation time, and the contraction time of the right ventricle were recorded at the level of the tricuspid annulus by using TDI. Then, the MPI was calculated. The patients were classified into the following three groups, according to the localization of the infarct-related artery (IRA) detected using coronary angiography: group I, proximal right coronary artery; group II, distal right coronary artery; and group III, circumflex coronary artery. RESULTS: RVMIs were detected in sixteen patients, and the IRA in 27 patients was the proximal right coronary artery. The right ventricular Sm was observed to be significantly low in patients with RVMIs and those in group I compared to those without RVMIs and those in groups II and III (10.9 +/- 1.3 vs 14.3 +/- 3.2 cm/s, respectively [p < 0.001]; 11.5 +/- 2.5 vs 15.1 +/- 3 cm/s, respectively; and 14.9 +/- 2.6 cm/s, respectively [p < 0.001]). In the diagnosis of RVMI, the values for sensitivity, specificity, negative predictive value, and positive predictive value of Sm < 12 cm/s were 81%, 82%, 92%, and 62% respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 63%, 88%, 74%, and 81%, respectively. The MPI was high in the same patient groups (0.83 +/- 0.12 vs 0.57 +/- 0.11 in those patients without RVMI, respectively, [p < 0.001]; 0.74 +/- 0.13 vs 0.56 +/- 0.15 in group II and 0.54 +/- 0.07 in group III, respectively [p < 0.001]). The sensitivity, specificity, negative predictive value, and positive predictive value of an MPI of > 0.70 in the diagnosis of RVMI were calculated as 94%, 80%, 97%, and 63%, respectively, and in the diagnosis of the proximal right coronary artery as the IRA, those values were 78%, 91%, 83%, and 88% respectively. CONCLUSIONS: An Sm <12 cm/s and an MPI > 0.70 obtained by TDI may define RVMI concomitant with acute inferior MI, and the IRA.

Case-Control Studies↗
PubMed1991

[Assessment of right atrial and ventricular function by radionuclide ventriculography using continuous infusion of 81mKr].

The purpose of this study is to assess the right atrial and ventricular function by radionuclide ventriculography using continuous infusion of 81mKr in normal subjects and in patients with heart disease. 1) Reproducibility of RVEF measurement by continuous infusion of 81mKr was good (interobserver; gamma = 0.97, p less than 0.001, n = 20: intraobserver; gamma = 0.97, p less than 0.001, n = 20). This method had a excellent correlation with RVEF of 99mTc first-pass technique (gamma = 0.92, p less than 0.001, n = 20). 2) RVEF was measured in 10 normal volunteers, 76 patients with myocardial infarction (OMI), 20 patients with dilated cardiomyopathy (DCM), 5 patients with arrhythmogenic right ventricular dysplasia (ARVD) and 5 patients with primary pulmonary hypertension (PPH). In OMI and DCM, their RVEF was lower than that of normal volunteers and, in ARVD and PPH, lower than that of OMI and DCM. There was a significant inverse correlation between RVEF, mean pulmonary artery pressure and right ventricular end-diastolic volume index. 3) The effect of the location of right coronary artery (RCA) lesions on RVEF during exercise was also evaluated. Ten normal volunteers and 27 patients with OMI were studied at rest and during exercise. The patients with OMI were divided into two groups: those without proximal RCA lesions (non RCA group, n = 12) and those with proximal RCA lesions (RCA group, n = 15). Although there were no significant increases of RVEF during exercise in both group, the percent change in RVEF was less in RCA group than in non RCA group. These findings suggested that proximal RCA stenosis is a major determinant of exercise RVEF. 4) To assess the right atrial function, right atrial volume curve was measured in 10 normal volunteers, 32 patients with OMI and 4 patients with PPH. The curve was clearly divided into 4 phase; filling phase (312 +/- 40 msec), early ejection phase (276 +/- 53 msec), plateau an index of right atrial reservoir function, was 0.41 +/- 0.05 and Contractile Volume/Stroke Volume (Contr. V/SV), as an index of right atrial pump function, was 0.23 +/- 0.05 in normal volunteers. In OMI and PPH, atrial reservoir function decreased and atrial pump function increased. It was concluded that radionuclide ventriculography using continuous infusion of 81mKr was useful to assess the right heart function.

Atrial Function, Right↗
PubMed1975

Pulmonary stenosis and impaired myocardial function.

Two young Black female patients with pulmonary valve stenosis and intact ventricular septa are presented in protracted congestive cardiac failure with severe tricuspid insufficiency and, in one, atrial fibrillation. Right ventricular systolic dysfunction was manifested by peak systolic pressures below systemic level, raised end-diastolic pressures and low cardiac output, but without right-to-left shunt. These findings are in strong contrast to those found in most patients with pulmonary stenosis of long standing, where persistent impairment of right ventricular function is diastolic with a high end-diastolic pressure and reversal of an interatrial shunt which result from poor right ventricular compliance. Evidence of left ventricular dysfunction was also present in both cases. Protracted heart failure in these patients is believed to have been the result of coincidental cardiomyopathy in a racial group highly predisposed to this disorder. A diagnostic appreciation of this phenomenon is important in the evaluation of heart disease in the Black, since cardiomyopathy may modify or even mask the features of the underlying disorder.

Adolescent↗
PubMed2002

The right and left ventricular function after surgical correction with pericardial monocusp in tetralogy of fallot: mid-term result.

BACKGROUND: Surgical repair of tetralogy of Fallot (TOF) with reconstruction of the right ventricular (RV) outflow tract invariably results in pulmonary regurgitation (PR). Chronic PR has been associated with RV dysfunction and ventricular arrhythmia. Pericardial monocusp has recently been used at Ramathibodi Hospital to preserve pulmonary valve function. OBJECTIVES: First, to study the competency of the pericardial monocusp, one-year after correction. Second, to assess the right and left ventricular (LV) functions after surgery. Third, to assess correlation between severity of PR and the characters of electrocardiography (ECG) and chest X-ray (CXR) after correction. METHOD: A cross-sectional study was conducted in patients who, had undergone total correction for TOF at least one year ago. The past medical history was retrospectively reviewed from the medical records. The patients who underwent surgical correction with and without pericardial monocusp were recruited into group I and group II, respectively. The clinical symptoms, QRS duration from ECG, and cardio-thoracic (CT) ratio from CXR were analyzed. From the echocardiographic standpoint, the LV systolic function was determined by LV fractional shortening (LVFS), whereas the RV systolic function was determined by the tricuspid annular plane systolic excursion (TAPSE). Restrictive physiology of the RV was determined by presence of antegrade flow across the pulmonary valve during diastole. RESULTS: Sixty four patients were enrolled in the study, 7 in group I and 57 in group II. The median follow-up time after the surgery was 6.5 years, which was 3 years in group I and 7 years in group II (p < 0.01). All patients in group I (100%) and 45 (80.4%) in group II had moderate or severe PR. The severity of PR, the RV and LV systolic functions were not statistically significantly different between the two groups (p > 0.01). The median of the LVFS was 32.4 per cent, and of the TAPSE was 10.5 mm. There was no restrictive physiology of the RV in all patients. There were no significant correlations between symptoms, CT-ratio, QRS duration and the severity of PR. CONCLUSIONS: The pericardial monocusp could neither reduce severity of PR nor improve right and left ventricular functions after 3 years follow-up post-operatively. However, the right and left ventricular performances in mid-term period remained insignificantly changed and severity of PR could not be predicted from symptoms and simple laboratory investigations.

Adolescent↗
PubMed1988

Determination of right ventricular ejection fraction by thermodilution technique--a comparison to biplane cineventriculography.

Determination of right ventricular ejection fraction (RVEF) provides information about global right ventricular function, which may be important for the management of patients with various heart diseases. Right ventricular ejection fraction can be determined by new thermodilution techniques using fast-response thermistors. To evaluate the validity of these methods, thermodilution measurements were compared with biplane cineventriculography in 22 patients undergoing cardiac catheterization. In all patients standard deviation of RVEF was below 5%. Mean RVEF, determined by thermodilution, was 52% +/- 9%, ranging from 32% to 71% and correlated significantly with the results of angiography (RVEF: 52% +/- 9%) (r = 0.80, SEE +/- 5%, n = 22, p less than 0.001). Correlation was good especially in patients with small right ventricles (less than 160 ml) (r = 0.91, SEE +/- 5%, n = 13, p less than 0.001), lower heart rates (less than 65/min) (r = 0.84, SEE = +/- 6%, n = 12, p less than 0.001) and cardiac output below 5.51/min (r = 0.88, SEE +/- 6%, n = 11, p less than 0.001). Thus, if valid catheter placement is possible, right ventricular ejection fraction can be determined by thermodilution technique with good reproducibility and sufficient accuracy compared to biplane angio. Validation of this method in larger patient populations with various heart diseases is necessary.

Aged↗
PubMed2000

[Ross operation in aortic valve diseases].

UNLABELLED: Currently used standard mechanical and bioprosthetic heart valves all have limitations that produce less than optimal results. The pulmonary autograft offers a promising alternative with theoretical advantages that have to be proven for final judgement of this innovative surgical technique. METHODS AND RESULTS: A survey including the international registry with 2523 patients enrolled since 1987 is provided along with the author's 10 years experience of 157 patients. The age of the patients ranges between one and 79 years. The indication is expanding integrating concomitant procedures like repair or replacement of aneurysms of the aortic root and ascending aorta, mitral valve reconstruction, coronary bypass grafting, etc. The operative mortality ranges between 0.6 and 2.5%. No anticoagulation is necessary. The function of the autograft is excellent. Late incidence of significant aortic insufficiency (> 2+) remains less than 5%. Even at exercise there is no pressure gradient across the autograft. Autograft failure with autograft revision or replacement stands at 1-4%. Homograft function is also found to be excellent. Right ventricular outflow tract revision rate ranges between 1-1.3%. In a few patients (7%), maximal pressure gradients between 20 and 35 mmHg developed across the homograft without major impairment of right ventricular function. CONCLUSIONS: The multicenter data confirm the superior performance of the autograft not matched by any other biological or mechanical valve replacement. Scientific efforts are required to further improve long-term function especially of the neopulmonary valve.

Adolescent↗