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CLINICAL RESEARCH: CONGENITAL HEART DISEASE

Restrictive Right Ventricular Physiology

Its Presence and Symptomatic Contribution in Patients With Pulmonary Valvular Stenosis

Yat-Yin Lam, MRCP^_*,,_*, Mehmet G. Kaya, MD^_*, Omer Goktekin, MD^_*, Michael A. Gatzoulis, MD, PhD^_*,, Wei Li, MD, PhD^_*,, and Michael Y. Henein, MSc, PhD^,||

^_* Adult Congenital Heart Unit, Royal Brompton Hospital, London, United Kingdom
Department of Echocardiography, Royal Brompton Hospital, London, United Kingdom
National Heart and Lung Institute, Imperial College, London, United Kingdom
Division of Cardiology, S. H. Ho Cardiovascular and Stroke Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China
^|| West Middlesex University Hospital, London, United Kingdom

Manuscript received March 5, 2007; revised manuscript received June 14, 2007, accepted June 25, 2007.

^_* Reprint requests and correspondence: Dr. Yat-Yin Lam, Adult Congenital Heart Unit, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, United Kingdom. (Email: homalam{at}hotmail.com).

Objectives: The aim of this study was to examine whether restrictive right ventricular (RV) physiology (the presence of antegrade pulmonary arterial flow in late diastole) occurred in patients with moderate to severe isolated pulmonary valvular stenosis (PVS) and to estimate its prevalence and relationship to RV function and patient symptoms.

Background: Little is published about RV diastolic performance in adult patients with PVS.

Methods: A total of 43 consecutive patients (age 44 ± 10 years) with moderate to severe PVS referred to Royal Brompton Hospital from 2002 to 2005 were retrospectively studied. Patient New York Heart Association (NYHA) functional class was recorded. The RV (lateral tricuspid annulus motion) long-axis movement was measured by M-mode and pulsed-wave (PW) tissue Doppler imaging (TDI). Restrictive RV physiology was assessed by PW Doppler echocardiography.

Results: Eighteen patients (42%) had restrictive RV physiology. They were more symptomatic (NYHA functional class 1.8 ± 0.5 vs. 1.3 ± 0.5; p < 0.001) and had poorer RV long-axis function (TDI peak systolic velocity 7.3 ± 2.1 cm/s vs. 9.7 ± 2.7 cm/s; TDI early diastolic velocity 6.6 ± 1.6 cm/s vs. 8.5 ± 2.4 cm/s; RV long-axis systolic amplitude 1.3 ± 0.2 cm vs. 1.5 ± 0.3 cm; p < 0.01 for all) compared with other PVS patients despite similar RV ejection fraction, myocardial performance index, and RV systolic pressure. The presence of restrictive RV physiology (odds ratio [OR] 6.05, 95% confidence interval [CI] 1.45 to 10.29; p = 0.01) and peak pulmonary valve pressure gradient (OR 1.07, 95% CI 1.01 to 1.13; p = 0.04) were the 2 independent echocardiographic predictors for decreased exercise tolerance in patients on multivariate analysis.

Conclusions: Restrictive RV physiology is common in PVS patients. Its presence is related to a worse deterioration in RV long-axis function and decreased exercise tolerance in patients.

Abbreviations and Acronyms   Ea = pulsed-wave tissue Doppler imaging early diastolic velocity   MPI = myocardial performance index   NYHA = New York Heart Association   PASP = pulmonary arterial systolic pressure   PV = pulmonary valve   PVS = pulmonary valvular stenosis   RAP = right atrial pressure   RV = right ventricular   RVSP = right ventricular systolic pressure   Sa = pulsed-wave tissue Doppler imaging peak systolic velocity   TDI = tissue Doppler imaging   TOF = tetralogy of Fallot

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