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Comparison of stroke work between repaired tetralogy of Fallot and normal right ventricular physiologies

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Abstract

Adult patients who underwent tetralogy of Fallot repair surgery (rTOF) confront life-threatening ailments due to right ventricular (RV) myocardial dysfunction. Pulmonary valve replacement (PVR) needs to be performed to restore the deteriorating RV function. Determination of correct timing to perform PVR in an rTOF patient remains subjective, due to the unavailability of quantifiable clinical diagnostic parameters. The objective of this study is to evaluate the possibility of using RV body surface area (BSA)-indexed stroke work (SWI) to quantify RV inefficiency in TOF patients. We hypothesized that RV SWI required to push blood to the lungs in rTOF patients is significantly higher than that of normal subjects. Seven patients with rTOF pathophysiology and eight controls with normal RV physiology were registered for this study. Right ventricular volume and pressure were measured using cardiac magnetic resonance imaging and catheterization, respectively. Statistical analysis was performed to quantify the difference in SWI between the RV of the rTOF and control groups. Right ventricular SWI in rTOF patients (0.176 ± 0.055 J/m2) was significantly higher by 93.4% (P = 0.0026) than that of controls (0.091 ± 0.030 J/m2). Further, rTOF patients were found to have significantly higher (P < 0.05) BSA normalized RV end-systolic volume, end-systolic pressure, and regurgitation fraction than control subjects. Ejection fraction and peak ejection rate of rTOF patients were significantly lower (P < 0.05) than those of controls. Patients with rTOF pathophysiology had significantly higher RV SWI compared with subjects with normal RV physiology. Therefore, RV SWI may be useful to quantify RV inefficiency in rTOF patients along with currently used clinical end points such as RV volume, pressure, regurgitation fraction, and ejection fraction.

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Acknowledgments

We regret to report the untimely demise of Dr William M. Gottliebson, who had a chance to review the data and the manuscript. We miss his everlasting enthusiasm and support for this study. The authors thank Amy Tipton (CCHMC) for reviewing RV volume contours. This study was funded in part by CCHMC and the University Research Council (URC), University of Cincinnati, Ohio, USA.

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Authors and Affiliations

  1. Mechanical Engineering, School of Dynamics Systems, University of Cincinnati, 593 Rhodes Hall, ML 0072, Cincinnati, OH, 45221, USA

    Namheon Lee, Ashish Das & Rupak K. Banerjee

  2. The Heart Institute, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA

    William M. Gottliebson

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  1. Namheon Lee
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  2. Ashish Das
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  3. Rupak K. Banerjee
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Correspondence to Rupak K. Banerjee.

Appendix

Appendix

Right ventricular stroke work calculation

The RV SW was estimated by calculating the area enclosed by RV P–V loop derived from the coregistered RV volume and pressure versus time curve [24]. The area enclosed by the P–V loop was calculated by applying the Gauss theorem. Applying the Gauss theorem to Eq. 2 we get

$$ {\text{RV}}\,{\text{SW}} = \iint\limits_{\text{A}} {pdV} = \frac{1}{2}\oint\limits_{\text{C}} {\left( {pdV - Vdp} \right)} $$
(3)

where p and V are RV pressure and volume, respectively, and C is the closed path of integration over one cardiac cycle. The right-hand side of Eq. 3 can be simplified to a summation over a sequence of sample points, \( \left( {p_1 ,V_1 } \right),\,\left( {p_2 ,V_2 } \right), \ldots ,\,\left( {p_n ,V_n } \right),\,\left( {p_1 ,V_1 } \right)\), along the P–V loop. The simplified equation is given by:

$$ {\text{RV}}\,{\text{SW}} = \left[ {\sum\limits_{i = 1}^{n - 1} \frac{1}{2} \left( {p_i V_{i + 1} - p_{i + 1} V_i } \right)} \right] + \frac{1}{2}\left( {p_n V_1 - p_1 V_n } \right) $$

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Lee, N., Das, A., Banerjee, R.K. et al. Comparison of stroke work between repaired tetralogy of Fallot and normal right ventricular physiologies. Heart Vessels 28, 76–85 (2013). https://doi.org/10.1007/s00380-011-0212-7

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