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Abnormal flow conduction through pulmonary arteries is associated with right ventricular volume and function in patients with repaired tetralogy of Fallot: does flow quality affect afterload?

  • Cardiac
  • Published:
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Abstract

Objectives

Flow through the proximal pulmonary arteries (PAs) of patients with repaired Tetralogy of Fallot (TOF) is known to be highly disordered and associated with significant regurgitation. The purpose of this study was to evaluate 4D-Flow MRI–derived viscous energy loss \( \Big({E}_L^{\prime } \))—as a result of non-efficient flow propagation, and relate this parameter to standard right ventricular (RV) size and function markers in patients with repaired TOF.

Methods

Thirty-five patients with TOF and 14 controls underwent comprehensive 4D-Flow MRI evaluation for qualitative flow analysis and to calculate \( {E}_L^{\prime } \) in the main and right pulmonary arteries. Sampled \( {E}_L^{\prime } \) indices were correlated with the MRI-derived RV size and functional indices.

Results

All patients with TOF exhibited abnormal, supra-physiologic helical/vortical formations in the PAs. Patients with TOF had significantly increased peak systolic \( {E}_L^{\prime } \) (8.0 vs 0.5 mW, p < 0.001), time-averaged \( {E}_L^{\prime } \) (2.5 vs. 0.2 mW, p < 0.001), and peak systolic \( {E}_L^{\prime } \) indexed to stroke volume (0.082 vs. 0.012 mW/mL, p < 0.001). \( {E}_L^{\prime } \) indexed to stroke volume correlated with the RV end-diastolic volume (R = 0.68, p < 0.001), end-systolic volume (R = 0.62, p < 0.001), ejection fraction (R = −0.45, p = 0.002), and cardiac index (R = 0.45, p = 0.002). The mean estimated energy loss due to \( {E}_L^{\prime } \) with regard to input RV mechanical power was 4.7%.

Conclusion

This study demonstrates that patients with repaired TOF have highly abnormal flow conduction through the PAs which result into extensive viscous energy loss. This significant flow-mediated energy loss is associated with the RV volume and function, and might represent considerable loss of mechanical power generated by each cardiac cycle. Future studies are required to assess whether the abnormal flow conduction adds to the RV afterload and remodeling.

Key points

• Abnormal flow patterns through proximal pulmonary arteries in patients with TOF are associated with excessive viscous energy loss.

• Inefficient flow conduction is associated with the RV dilation and reduced function and might contribute to the RV adaptive remodeling.

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Abbreviations

4D-Flow MRI:

Four-dimensional flow magnetic resonance imaging

E L ′ :

Viscous energy loss

LPA:

Left pulmonary artery

MPA:

Main pulmonary artery

PA:

Pulmonary artery

RPA:

Right pulmonary artery

RV:

Right ventricle

TOF:

Tetralogy of Fallot

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Funding

This study was supported by a generous gift from the Rady Family Foundation and Jayden DeLuca Foundation. AJB is supported in part by NIH K25HL119608 and R01HL133504.

Author information

Author notes

  1. D. McLennan and M. Schäfer contributed equally to this manuscript.

Authors and Affiliations

  1. Division of Cardiology, Department of Pediatrics, Heart Institute, Children’s Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, 13123 E 16th Ave, Aurora, CO, 80045-2560, USA

    Daniel McLennan, Michal Schäfer, D. Dunbar Ivy & Gareth J. Morgan

  2. Department of Radiology, Children’s Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA

    Alex J. Barker & Lorna P. Browne

  3. Department of Bioengineering, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA

    Alex J. Barker

  4. Department of Pediatric Heart Surgery, Children’s Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA

    Max B. Mitchell

  5. Division of Pediatric Cardiac Anesthesiology, Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado Denver | Anschutz Medical Campus, Aurora, CO, USA

    Richard J. Ing

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  1. Daniel McLennan
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Correspondence to Michal Schäfer.

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Guarantor

The scientific guarantor of this publication is Michal Schäfer.

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The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

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Written informed consent was waived by the Institutional Review Board.

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1. Schäfer M, Browne LP, Jaggers J, et al (2020) Abnormal left ventricular flow organization following repair of tetralogy of Fallot. J Thorac Cardiovasc Surg.

2. Schäfer M, Browne LP, Morgan GJ, et al (2018) Reduced proximal aortic compliance and elevated wall shear stress after early repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 156:2239–2249.

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  • case-control study

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McLennan, D., Schäfer, M., Barker, A.J. et al. Abnormal flow conduction through pulmonary arteries is associated with right ventricular volume and function in patients with repaired tetralogy of Fallot: does flow quality affect afterload?. Eur Radiol 33, 302–311 (2023). https://doi.org/10.1007/s00330-022-09017-6

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