Changes in right ventricular function in neonates with hypoplastic left heart syndrome before and after the hybrid procedure.

AIMS: Decreased right ventricular function via deformation analysis has been noted in patients with hypoplastic left heart syndrome (HLHS) after the Norwood procedure. No data exist in HLHS patients undergoing the hybrid procedure. The goal of this study was to evaluate right ventricular functional changes in HLHS patients undergoing the hybrid procedure under steady-state conditions. METHODS AND RESULTS: Echocardiograms were prospectively obtained on patients with HLHS before and after the hybrid procedure. Fractional area change, tricuspid inflow velocities, tissue Doppler imaging (TDI), and deformation analysis were performed. Paired Wilcoxon's signed rank or Student's t-test was used for analysis. P < 0.05 was considered significant. Twenty HLHS patients were studied (10 males:10 females). Median age at the pre-hybrid echocardiogram was 3 (1-16) days, age at hybrid procedure was 5 (3-17) days, and age at post-hybrid echocardiogram was 10 (6-34). There were significant decreases in systolic function as measured by TDI and deformation analysis. There was no significant change in right ventricular fractional area change. Diastolic function was also noted to significantly decrease after the hybrid procedure. CONCLUSION: Systolic and diastolic functions decreased after the hybrid procedure despite the fact that patients avoided cardiopulmonary bypass. These results are comparable with previous reports in HLHS patients undergoing the Norwood procedure. Further studies are needed to determine if these echocardiographic changes have prognostic significance.

Echocardiographic parameters that predict outcome in aortic atresia patients undergoing comprehensive stage II procedure.

BACKGROUND: The hybrid procedure is one option for palliating patients with hypoplastic left heart syndrome. As experience increases with this palliation, the physiology and its influence on outcome can be better assessed. The goal of this study was to determine if echocardiographic parameters correlate with post-operative variables in patients with aortic atresia undergoing the comprehensive Stage II procedure. METHODS: Retrospective chart review on all patients with aortic atresia, who underwent the comprehensive Stage II procedure from January 2002 to December 2008, was performed. Echocardiographic indices were evaluated and correlations were made with peri-operative and hospital variables. Pair-wise Pearson's correlation tests were used to analyze the associations between continuous measures. RESULTS: Thirty-four patients met inclusion criteria. Age at comprehensive Stage II procedure was 0.45 ± 0.13 years and body surface area was 0.31 ± 0.04 m(2). Right ventricle (RV) percentage change was 45 ± 10%, eccentricity index was 1.96 ± 0.45, estimated systemic cardiac output was 7.68 ± 2.56 L/min/m(2) and estimated effective systemic cardiac output was 5.15 ± 2.24 L/min/m(2). Retrograde patent ductus arteriosu (PDA) velocity time integral (VTI) correlated with log pre-bypass lactate and maximum lactate (r = 0.53, 0.44). PDA regurgitant fraction correlated with log post-bypass lactate, length of intubation, and urine output on day four (r = 0.39, 0.46, -0.37). RV percentage change correlated with log pre-bypass lactate, and urine output on days four and five (r =-0.38, 0.43, 0.54). No echocardiographic parameter predicted renal or liver insufficiency, dialysis, extracorporeal membrane oxygenation use, or hospital death. CONCLUSION: Retrograde PDA VTI and RV percent change correlated with some peri-operative variables though no echocardiographic parameter was associated with any major morbidities or mortality. Newer echocardiographic techniques may better predict comprehensive stage II outcomes.

Interstage echocardiographic changes in patients undergoing hybrid stage I palliation for hypoplastic left heart syndrome.

OBJECTIVE: The hybrid procedure is an alternative for initial palliation for patients with hypoplastic left heart syndrome. No echocardiographic data exist for the interstage (IS) period. The goal of this study was to describe the echocardiographic changes during this period. METHODS: A chart review was performed on patients discharged from the hospital with the diagnosis of hypoplastic left heart syndrome who underwent hybrid palliation. Echocardiograms at hospital discharge (post-hybrid), before and after any IS interventions, and before comprehensive stage II procedure were reviewed. Distal right pulmonary artery (RPA) and left pulmonary artery (LPA) velocity, slope, velocity time integral (VTI), pressure halftime (p1/2), pulsatility index (PI), and systolic/diastolic (S/D) ratio of the waveforms were recorded. Atrial septal defect (ASD) mean gradient, ductus arteriosus peak velocity, retro-aortic arch peak velocity, tricuspid regurgitation (TR), and right ventricular function were documented. Exploratory hypotheses were tested with chi-square and t tests. Stepwise logistic regression was used to identify any multiple sets of relatively independent variables. RESULTS: Thirty patients met inclusion criteria. Fourteen patients underwent 22 different interventions at the atrial septum, ductus arteriosus, or retro-aortic arch in the IS period. Baseline ASD gradient (P = .012) and ductus arteriosus velocity (P = .002) predicted an IS intervention. There were significant differences in LPA and RPA VTI (P = .011, .03), p1/2 (P = .038, .008), and S/D (P = .012, .033); RPA slope (P = .013); ASD gradient (P = .003); ductus arteriosus velocity (P = .021); and TR (P = .031) before and after an intervention. There were significant differences in post-hybrid versus pre-comprehensive stage II LPA and RPA VTI (P = .009, .022), PI (P = .031, .022), and peak velocity (P = .004, .037); RPA S/D (P = .025) and p1/2 (P = .029); ductus arteriosus velocity (P < .001); retro-aortic arch peak velocity (P = .035); and ASD mean gradient (P < .001). Pre-comprehensive stage II function tended to predict death (P = .085). CONCLUSION: Echocardiographic parameters help predict IS course and guide clinical therapy for this patient population.