Stroke volume ratio derived from magnetic resonance imaging as an indicator of interventricular dyssynchrony predicts future cardiac event in patients with biventricular Fontan circulation
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The prognostic factors in patients with biventricular heart who underwent Fontan surgery remain unclear. This study wanted to assess the hypothesis that interventricular dyssynchrony evaluated by cardiac magnetic resonance imaging (MRI) can predict future cardiac events in patients with biventricular heart who have undergone Fontan surgery. We prospectively enrolled consecutive patients with biventricular Fontan circulation from 2003 to 2016, and performed protocolized cardiac MRI. We determined the stroke volume ratio (SVr) using the following formula to assess interventricular dyssynchrony: (stroke volume (SV) of the two whole ventricles)/(SV of the right ventricle + SV of the left ventricle), by tracing cine MRI data. If interventricular dyssynchrony existed, blood flowed and returned to each ventricle through the ventricular septal defect; therefore, the SVr in this instance should be less than 1.0. We enrolled 40 patients. SVr ranged from 0.81 to 1.0 (median 0.95). Low SVr (< 0.95) was associated with worse New York Heart Association functional class, longer QRS duration, right bundle branch block, low biventricular indexed stroke volume, and low biventricular ejection fraction. During the follow-up period (median 53.5 months), 10 cardiac events occurred (six cases of acute exacerbation of heart failure, three cases of supraventricular tachycardia, and one case of exacerbation of protein-losing enteropathy). Univariate analysis showed four clinical predictors: SVr < 0.95 [hazard ratio (HR) 9.3, 95% confidential interval (CI) 1.7–171.5]; biventricular ejection fraction < 0.45 (HR 9.4, 95% CI 2.2–65.3); left ventricular indexed end-diastolic volume > 73 mL/m2 (HR 4.5, 95% CI 1.1–15.7); and the presence of the aorta directly arising from the right ventricular conus (HR 5.8, 95% CI 1.1–106). SVr derived from MRI can predict future cardiac events in Fontan patients with biventricular hearts.
KeywordsFontan Biventricular heart Dyssynchrony Stroke volume ratio Prognostic factors
Cardiac resynchronization therapy
Left bundle branch block
Magnetic resonance imaging
New York Heart Association
Right bundle branch block
- ROC curve
Receiver-operating characteristic curve
Percutaneous oxygen saturation
Stroke volume ratio
Ventricular septal defect
We would like to thank Editage (http://www.editage.jp) for English language editing.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The ethical committee in our hospital also gave approval, and all subjects provided their informed consent for cardiac MRI.
Human and animal rights statement
This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
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