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CLINICAL RESEARCH: CONGENITAL HEART DISEASE

Time Course of Diastolic and Systolic Function Improvement After Pulmonary Valve Replacement in Adult Patients With Tetralogy of Fallot

Alexander van Straten, MD^_*,_*, Hubert W. Vliegen, MD, PhD, Hildo J. Lamb, MD, PhD^_*, Stijntje D. Roes, MD^_*,, Ernst E. van der Wall, MD, PhD, Mark G. Hazekamp, MD, PhD and Albert de Roos, MD, PhD^_*

^_* Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands

Manuscript received December 19, 2004; revised manuscript received June 16, 2005, accepted June 21, 2005.

^_* Reprint requests and correspondence: Dr. Alexander van Straten, Department of Radiology, C2-S, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands (Email: A.van_Straten{at}LUMC.nl).

OBJECTIVES: The aim of this research was to assess right ventricular diastolic and systolic function before and after pulmonary valve replacement (PVR) in adult patients after repair of tetralogy of Fallot.

BACKGROUND: Pulmonary valve replacement (PVR) in adult patients late after repair of tetralogy of Fallot leads to rapid improvement of right ventricular (RV) systolic function.

METHODS: A total of 16 patients and 8 healthy subjects were included. Median age at initial repair was 4.9 (0.9 to 13.1) years, and mean age at PVR was 28.7 (19.5 to 45.6) years. Cardiac magnetic resonance imaging was performed before and 8 and 22 months after PVR. Right ventricular volumes and function as well as RV in- and outflow patterns were assessed.

RESULTS: The volume of the early filling of the RV (Evol) increased from 49.8 ± 14.7 ml to 53.8 ± 19.3 ml (not significant) and 62.0 ± 18.9 ml, respectively (p < 0.05), whereas the volume of the atrial contraction (Avol) remained unchanged. Consequently, the Evol/Avol ratio increased from 1.4 ± 0.7 before PVR to 1.6 ± 0.7 at 8 months (not significant) and 2.3 ± 1.2 at 22 months (p < 0.01). The Evol/Avol ratio was not significantly different from the healthy subjects at 22 months, indicating late recovery of diastolic function. Systolic function improved rapidly after PVR; the indexed RV end-systolic volume decreased from 93.7 ± 33.0 ml/m² to 60.9 ± 18.4 ml/m² (p < 0.01) and 54.8 ± 21.0 ml/m² (p < 0.01).

CONCLUSIONS: In adult patients late after total repair of Fallot, PVR leads to late improvement of diastolic function. We speculate that the rapid volume unloading after PVR increases systolic performance, whereas improvement in diastolic function requires long-term remodeling.

Abbreviations and Acronyms   A = tricuspid inflow peak due to atrial contraction   E = tricuspid early filling peak   EDFF = end-diastolic forward flow in the main pulmonary artery   EF = ejection fraction   pfr = peak flow rate   PR = pulmonary regurgitation   PVR = pulmonary valve replacement   RV-EDV-I = right ventricular end-diastolic volume, indexed for body surface area   RV-ESV-I = right ventricular end-systolic volume, indexed for body surface area

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