Decreased biventricular longitudinal strain shortly after congenital heart defect surgery.

OBJECTIVE: Impaired ventricular performance in patients who underwent surgery for congenital heart defect (CHD) may ultimately result in clinical heart failure. It is therefore important to regularly evaluate the left ventricular (LV) and right ventricular (RV) performance. We evaluated tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) before and after surgical correction of a CHD. STUDY DESIGN: Patients with CHD undergoing biventricular corrective surgery were included in this retrospective study. In addition, a group of healthy controls was included. The performance of LV, RV and interventricular septum (IVS) was assessed using mitral inflow velocities, TDI peak systolic (S'), peak early (E') and peak late (A') diastolic velocity. LV and RV global longitudinal strain (GLS) were assessed using STE. Measurements were performed preoperatively and at discharge. RESULTS: A total of 204 patients and 78 controls were included. All TDI measurements were significantly decreased after surgery. Nonetheless, LV S' and A' were still within normal limits. LV and RV GLS were significantly reduced after surgery and significantly lower compared to controls. A longer aortic cross-clamp time and cardiopulmonary bypass (CPB) time were associated with significantly lower TDI and strain parameters in the RV and IVS, but not in the LV. CONCLUSION: TDI and STE results generally imply a significantly lower ventricular performance in patients with CHD postoperatively. Furthermore, a negative correlation was observed between aortic cross-clamping and CPB time and several RV performance parameters. As this association was not observed in the LV, this could implicate less vulnerability of the LV to cardiopulmonary bypass.

Distribution of strain patterns in children with dilated cardiomyopathy.

OBJECTIVES: This study aimed to evaluate the predicting value of quantitative and qualitative dyssynchrony parameters as assessed by two-dimensional speckle tracking echocardiography (STE) on outcome in children with dilated cardiomyopathy (DCM). Furthermore, the reproducibility of these parameters was investigated. BACKGROUND: In previous studies in adults with heart failure, several dyssynchrony parameters have been shown to be a valuable predictor of clinical outcome. METHODS: This multicenter, prospective study included 75 children with DCM and 75 healthy age-matched controls. Using STE, quantitative (time to global peak strain and parameters describing intraventricular time differences) and qualitative dyssynchrony parameters (pattern analysis) of the apical four-chamber, three-chamber, two-chamber views, and the short axis of the left ventricle were assessed. Cox regression was used to identify risk factors for the primary endpoints of death or heart transplantation. Inter-observer and intra-observer variability were described. RESULTS: During a median of 21 months follow-up, 10 patients (13%) reached an endpoint. Although quantitative dyssynchrony measures were higher in patients as compared to controls, the inter-observer and intra-observer variability were high. Pattern analysis showed mainly reduced strain, instead of dyssynchronous patterns. CONCLUSIONS: In this study, quantitative dyssynchrony parameters were not reproducible, precluding their use in children. Qualitative pattern analysis showed predominantly reduced strain, suggesting that in children with DCM dyssynchrony may be a minor problem.

Ventricular performance after surgery for a congenital heart defect as assessed using advanced echocardiography: from doppler flow to 3D echocardiography and speckle-tracking strain imaging.

A varying degree of impairment of ventricular performance is observed over the long-term after surgery for a congenital heart defect (CHD). Impaired ventricular performance has been shown to be of prognostic value for increased risk of cardiovascular events in adult CHD patients. This emphasizes the importance of delineating the timing and cause of this postoperative impairment. Impairment of ventricular performance could develop over time as a consequence of residua, sequelae and complications of the CHD or surgical procedure. Yet, impaired ventricular performance has also been observed immediately after surgery and can persist and/or worsen over time. This postoperative impairment of ventricular performance is the focus of this review. This article provides an overview of echocardiographic techniques currently used to assess ventricular performance. Furthermore, we review current literature describing ventricular performance, as assessed using echocardiography, after correction of a CHD. In general, a decrease in ventricular performance is observed directly after surgery for CHD's. Subsequent follow-up of ventricular performance is characterized by a varying degree of postoperative recovery. A consistent observation is the persistent impairment of right-ventricular performance after repair in several different subgroups of CHD patients ranging from ventricular septal defect repair to surgery for Tetralogy of Fallot.

Tissue Doppler imaging detects impaired biventricular performance shortly after congenital heart defect surgery.

Cardiac surgery with cardiopulmonary bypass is associated with the development of a systemic inflammatory response, which can lead to myocardial damage. However, knowledge concerning the time course of ventricular performance deterioration and restoration after correction of a congenital heart defect (CHD) in pediatric patients is sparse. Therefore, the authors perioperatively quantified left ventricular (LV) and right ventricular (RV) performance using echocardiography. Their study included 141 patients (ages 0-18 years) undergoing CHD correction and 40 control subjects. The study assessed LV systolic performance (fractional shortening) and diastolic performance (mitral Doppler flow) in combination with RV systolic performance [tricuspid annular plane systolic excursion (TAPSE)] and diastolic performance (tricuspid Doppler flow). Additionally, systolic (S') and diastolic (E', A', E/E') tissue Doppler imaging (TDI) measurements were obtained at the LV lateral wall, the interventricular septum, and the RV free wall. Echocardiographic studies were performed preoperatively, 1 day postoperatively, and at hospital discharge after 9 ± 5 days. Although all LV echocardiographic measurements showed a deterioration 1 day after surgery, only LV TDI measurements were impaired in patients at discharge versus control subjects (S': 5.7 ± 2.0 vs 7.1 ± 2.7 cm/s; E': 9.8 ± 3.9 vs 13.7 ± 5.1 cm/s; E/E': 12.2 ± 6.4 vs 8.8 ± 4.3; p < 0.05). In the RV, TAPSE and RV TDI velocities also were impaired in patients at discharge versus control subjects (TAPSE: 9 ± 3 vs 17 ± 5 mm; S': 5.2 ± 1.7 vs 11.4 ± 3.4 cm/s; E': 7.3 ± 2.5 vs 16.3 ± 5.2 cm/s; E/E': 12.5 ± 6.8 vs 4.8 ± 1.9; p < 0.05). Furthermore, longer aortic cross-clamp times were associated with more impaired postoperative LV and RV performance (p < 0.05). In conclusion, both systolic and diastolic biventricular performances were impaired shortly after CHD correction. This impairment was detected only by TDI parameters and TAPSE. Furthermore, a longer-lasting negative influence of cardiopulmonary bypass on myocardial performance was suggested.

Tissue Doppler imaging in the left ventricle and right ventricle in healthy children: normal age-related peak systolic velocities, timings, and time differences.

AIMS: Tissue Doppler imaging (TDI) enables assessment of velocities and timings within the left (LV) and the right (RV) ventricle with high temporal resolution. Knowledge on normal age-related values of peak systolic velocities and timings in healthy children may optimize the benefit of device-based therapies in paediatric patients with heart failure. METHODS AND RESULTS: A total of 123 healthy children (from 1 month to 18 years old) underwent TDI evaluation of the RV and LV. Peak systolic velocity and time to peak systolic velocity were assessed at the basal LV lateral wall, inter-ventricular septum (IVS), RV free wall (RVFW), and at the RV outflow tract (RVOT). Intra-ventricular time differences were calculated. Regression analysis was performed to assess the age dependency of the ventricular mechanics. Median peak velocities were: LV lateral wall: 6.3 cm/s (inter-quartile range (IQR): 5.1-7.9 cm/s); IVS: 6.0 cm/s (5.4-6.7 cm/s); RVFW: 10.2 cm/s (8.9-11.3 cm/s); RVOT: 7.2 cm/s (6.0-8.2 cm/s). Timings of peak systolic velocities were: LV lateral wall: 101 ms (91-112 ms); IVS: 114 ms (100-128 ms); RVFW: 177 ms (157-194 ms); RVOT: 100 ms (88-113 ms). Timings and peak velocities significantly increased with age at both ventricles. No relevant time difference was observed within the LV, whereas a considerable time delay was observed within the RV between the RVFW and the IVS (62 ms, IQR: 45-74 ms) and between the RVFW and the RVOT (74 ms, IQR: 59-93 ms). CONCLUSION: The present evaluation provides TDI-derived physiological values on normal LV and RV mechanics of healthy children. Within the LV, no relevant time difference was observed, whereas a considerable mechanical delay is observed within the healthy RV.

Left and right ventricular performance after arterial switch operation.

OBJECTIVE: Recent descriptions of decreased exercise capacity 10 to 15 years after arterial switch operation (ASO) suggest subclinical hemodynamic restrictions. Persistent impairment of ventricular performance following ASO may add to this. We aimed to characterize the time course of changes in biventricular performance within the first year following ASO. METHODS: We prospectively included 26 patients with transposition of the great arteries undergoing ASO and 20 age-matched controls. Left and right ventricular systolic and diastolic performance was assessed using tissue Doppler imaging-derived peak systolic velocity, peak diastolic velocity, and peak early wave Doppler flow velocity/early diastolic tissue Doppler imaging velocity as well as mitral and tricuspid annular plane systolic excursion. Furthermore, left ventricular longitudinal, radial, and circumferential strain were assessed using speckle tracking strain imaging. Studies were performed preoperatively, 1 day postoperatively, at discharge, and at medium-term follow-up (9 months [interquartile range, 6-23 months] postoperatively). RESULTS: After an initial decrease in biventricular systolic and diastolic performance 1 day postoperatively versus preoperatively, recovery was observed in all parameters during medium-term follow-up. At medium-term follow-up left ventricular systolic and diastolic performance parameters were comparable in patients and controls. In contrast, right ventricular systolic and diastolic performance were still impaired in patients versus controls roughly 1 year postoperatively (tricuspid annular plane systolic excursion, 11.6 ± 2.2 vs 18.6 ± 3.1 mm; right ventricular peak systolic velocity, 8.1 ± 2.3 vs 12.6 ± 1.8 cm/second; right ventricular peak diastolic velocity, 12.4 ± 3.0 vs 18.2 ± 4.2 cm/second; and right ventricular peak early wave Doppler flow velocity/early diastolic tissue Doppler imaging velocity, 6.7 ± 2.1 vs 4.3 ± 1.3; all Ps < .001). CONCLUSIONS: If early ASO is performed, left ventricular performance recovers to control values within the first postoperative year. In contrast, right ventricular systolic and diastolic performance remained impaired during follow-up, which stresses the importance of postoperative follow-up of right ventricular performance.

Longitudinal follow-up of ventricular performance in healthy neonates.

BACKGROUND: Specific follow-up of newly introduced echocardiographic parameters in healthy neonates and infants is limited. AIM: To prospectively describe follow-up of left ventricular (LV) tissue Doppler imaging (TDI) and speckle tracking strain parameters in healthy subjects up to two months after birth. DESIGN: This is a longitudinal follow-up study. SUBJECTS: Twenty-eight (10 male) healthy newborns were included and underwent transthoracic echocardiography 1-3 days, 3 weeks and 6-7 weeks after birth. OUTCOME MEASURES: In each echocardiogram, parameters describing cardiac growth, including LV mass (LVM), were assessed. Additionally, TDI derived peak systolic velocity (S') and peak early (E') and late (A') diastolic velocities were assessed in the basal LV free wall and interventricular septum (IVS). Finally LV longitudinal, radial and circumferential global peak strain parameters were assessed using speckle tracking strain imaging. RESULTS: LVM significantly increased during follow-up (7.6 ± 2.4 versus 12.4 ± 3.2g, p = 0.002). Similarly at 1-3 days versus 6-7 weeks after birth, an increase in LV and IVS systolic (LV S' 4.1 ± 1.5 versus 6.3 ± 1.5 cm/s, p = 0.001; IVS S' 3.6 ± 0.9 versus 6.4 ± 1.3 cm/s, p < 0.001) and diastolic (LV E' 6.1 ± 2.2 versus 9.7 ± 2.9 cm/s, p = 0.002; IVS E' 5.1 ± 1.4 versus 10.7 ± 3.3 cm/s, p < 0.001) TDI parameters was observed. In contrast, global peak longitudinal, radial and circumferential strain parameters did not significantly change during follow-up. CONCLUSIONS: A significant increase in LV systolic and diastolic TDI parameters was observed up to two months after birth. Yet this increase may be (cardiac) growth-dependent. No significant changes were observed in speckle tracking strain derived global peak strain parameters; this may render the technique particularly valuable in evaluation of LV systolic performance during periods of significant growth, such as the neonatal period.

Assessment of intraventricular time differences in healthy children using two-dimensional speckle-tracking echocardiography.

BACKGROUND: Parameters describing intraventricular time differences are increasingly assessed in both adults and children. However, to appreciate the implications of these parameters in children, knowledge of the applicability of adult techniques in children is essential. Hence, the aim of this study was to assess the applicability of speckle-tracking strain-derived parameters in children, paying special attention to age and heart rate dependency. METHODS: One hundred eighty-three healthy subjects (aged 0-19 years) were included. Left ventricular global peak strain, time to global peak strain, and parameters describing intraventricular time differences were assessed using speckle-tracking strain imaging in the apical two-chamber, three-chamber, and four-chamber views (longitudinal strain) and the parasternal short-axis view (radial and circumferential strain). Parameters describing intraventricular time differences included the standard deviation of time to peak strain and differences in time to peak strain between two specified segments. Age and heart rate dependency were evaluated using regression analysis, and intraobserver and interobserver variability were tested. RESULTS: Acquisition and analysis of longitudinal six-segment time-strain curves was successful in 94.8% of subjects and radial and circumferential time-strain curves in 89.5%. No clinically significant linear relation was observed between age or heart rate and parameters describing intraventricular time differences. The coefficient of variation of time to global peak strain parameters was <10, while it was >10 for parameters describing intraventricular time differences. CONCLUSIONS: The feasibility of speckle-tracking strain analysis in children is relatively good. Furthermore, no linear relation was observed between age or heart rate and parameters describing intraventricular time differences. However, the limited reproducibility of some parameters describing intraventricular time differences will confine their applicability in clinical practice.

Enhanced characterization of ventricular performance after coarctation repair in neonates and young children.

BACKGROUND: Within the group of patients undergoing coarctectomy today, two subgroups can be identified: neonates with a critical coarctation and nonneonatal patients. We hypothesize that patients who have to undergo repair in the neonatal period will have more persistent impairment of ventricular performance postoperatively. Accordingly, we aimed to characterize biventricular performance after coarctectomy in neonatal and nonneonatal patients. METHODS: Children (aged 0 to 17 years) undergoing a coarctectomy were prospectively included and classified as neonatal (<1 month old) or nonneonatal patients. Age-matched controls were included for each measurement occasion. To evaluate left (LV) and right ventricular (RV) performance, fractional shortening, peak systolic (S') and early diastolic (E') tissue Doppler imaging velocities, and E/E' were assessed preoperatively, at discharge, and 1 year postoperatively (11.4 ± 8.3 months). RESULTS: In neonatal (n = 18) and nonneonatal (n = 19) patients LV performance significantly improved within the first postoperative year. Yet 1 year postoperatively, LV S' was still lower in neonatal patients vs controls (4.8 ± 1.1 vs 6.1 ± 1.6 cm/s; p = 0.036), whereas comparable results were observed in nonneonatal patients and controls. One year postoperatively, LV diastolic performance was impaired in neonatal (LV E' 8.7 ± 3.1 vs 13.2 ± 3.9 cm/s, p = 0.005) and nonneonatal patients (LV E' 12.1 ± 3.5 vs 15.1 ± 2.4 cm/s, p = 0.008) vs controls. In RV performance variables, no differences were observed 1 year postoperatively between neonatal and nonneonatal patients and controls. CONCLUSIONS: In both subgroups, LV diastolic performance does not recover to normal values within the first postoperative year. However, LV systolic performance remains more persistently impaired in patients who have to undergo repair in the neonatal period vs nonneonatal repair.

Disparity in right vs left ventricular recovery during follow-up after ventricular septal defect correction in children.

OBJECTIVES: Long-term prognosis after ventricular septal defect (VSD) correction in childhood is excellent. Nevertheless, decreased biventricular systolic performance has been described immediately following VSD surgery in children. In an effort to better understand this decrease and its time-course, we characterized biventricular systolic performance following VSD closure in paediatric patients up to 20 months postoperatively. METHODS: Thirty-nine children undergoing VSD surgery and 22 age-matched controls were included for echocardiographic follow-up of left (LV) and right ventricular (RV) systolic performance. LV fractional shortening and tricuspid annular plane systolic excursion (TAPSE) were assessed. Additionally, tissue Doppler imaging measurements were obtained at the basal LV lateral wall and RV free wall to assess both LV and RV systolic (S(')) performance. Studies were performed preoperatively, 1 day postoperatively, at discharge and 3-20 months postoperatively at medium-term follow-up. RESULTS: After an initial decrease in biventricular systolic performance, a significant recovery was observed within the first year after VSD surgery. After a medium-term follow-up of 8.4 ± 5.3 months, LV systolic performance parameters were normalized, while RV systolic performance parameters remained impaired in patients vs controls (TAPSE: 12.5 ± 1.2 vs 18.5 ± 3.2 mm, RV S('):8.9 ± 1.3 vs 12.5 ± 2.2 cm/s). CONCLUSIONS: Within the first year after VSD correction, LV systolic performance had normalized, while RV systolic performance remained significantly impaired up to 20 months after VSD closure. Both detrimental effects of open heart surgery with cardiopulmonary bypass and preoperative alterations may add to the observed postoperative impairment of specifically RV performance.