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Impact of right ventricular stiffness on discordance between hemodynamic parameter and regurgitant volume in patients with pulmonary regurgitation

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Abstract

Background: Accurate detection of significant pulmonary regurgitation (PR) is critical in management of patients after right ventricular (RV) outflow reconstruction in Tetralogy of Fallot (TOF) patients, because of its influence on adverse outcomes. Although pressure half time (PHT) of PR velocity is one of the widely used echocardiographic markers of the severity, shortened PHT is suggested to be seen in conditions with increased RV stiffness with mild PR. However, little has been reported about the exact characteristics of patients showing discrepancy between PHT and PR volume in this population. Methods: Echocardiography and cardiac magnetic resonance imaging (MRI) were performed in 74 TOF patients after right ventricular outflow tract (RVOT) reconstruction [32 ± 10 years old]. PHT was measured from the continuous Doppler PR flow velocity profile and PHT < 100 ms was used as a sign of significant PR. Presence of end-diastolic RVOT forward flow was defined as RV restrictive physiology. By using phase-contrast MRI, forward and regurgitant volumes through the RVOT were measured and regurgitation fraction was calculated. Significant PR was defined as regurgitant fraction ≥ 25%. Results: Significant PR was observed in 54 of 74 patients. While PHT < 100 ms well predicted significant PR with sensitivity of 96%, specificity of 52%, and c-index of 0.72, 10 patients showed shortened PHT despite regurgitant fraction < 25% (discordant group). Tricuspid annular plane systolic excursion and left ventricular (LV) ejection fraction were comparable between discordant group and patients showing PHT < 100 ms and regurgitant fraction ≥ 25% (concordant group). However, discordant group showed significantly smaller mid RV diameter (30.7 ± 4.5 vs. 39.2 ± 7.3 mm, P < 0.001) and higher prevalence of restrictive physiology (100% vs. 42%, P < 0.01) than concordant group. When mid RV diameter ≥ 32 mm and presence of restrictive physiology were added to PHT, the predictive value was significantly improved (sensitivity: 81%, specificity: 90%, and c-index: 0.89, P < 0.001 vs. PHT alone by multivariable logistic regression model). Conclusion: Patients with increased RV stiffness and non-enlarged right ventricle showed short PHT despite mild PR. Although it has been expected, this was the first study to demonstrate the exact characteristics of patients showing discrepancy between PHT and PR volume in TOF patients after RVOT reconstruction.

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Abbreviations

ACHD:

Adult congenital heart disease

EDV:

End-diastolic volume

ERO:

Effective regurgitant orifice

ESV:

End-systolic volumes

FAC:

Fractional area change

IQR:

Interquartile range

IVCD:

Inferior vena cava dimension

LV:

Left ventricular

MRI:

Magnetic resonance imaging

PHT:

Pressure half time

PR:

Pulmonary regurgitation

RV:

Right ventricular

RVOT:

Right ventricular outflow tract

ROC:

Receiver operating characteristic

SV:

Stroke volume

TAPSE:

Tricuspid annular plane systolic excursion

TOF:

Tetralogy of Fallot

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Acknowledgements

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Funding

This research did not receive any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, 060-8638, Sapporo, Japan

    Ko Motoi, Suguru Ishizaka, Yoji Tamaki, Hiroyuki Aoyagi, Kosuke Nakamura & Toshihisa Anzai

  2. Division of Cardiology, Teine Keijinkai Hospital, 1-12-1-40,Maeda,Teine-ku, 006- 8555, Sapporo, Japan

    Hiroyuki Iwano

  3. Department of Diagnostic and Interventional Radiology, Hokkaido University Hospital, Kita- 14, Nishi-5, Kita-ku, 060-8638, Sapporo, Japan

    Satonori Tsuneta

  4. Diagnostic Center for Sonography, Hokkaido University Hospital, Kita-14, Nishi-5, Kita-ku, 060-8648, Sapporo, Japan

    Hiroyuki Iwano & Michito Murayama

  5. Division of Clinical Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita- 14, Nishi-5, Kita-ku, 060-8648, Sapporo, Japan

    Masahiro Nakabachi, Shinobu Yokoyama & Hisao Nishino

  6. Faculty of Health Sciences, Hokkaido University, Kita-12, Nishi-5, Kita-ku, 060-0812, Sapporo, Japan

    Sanae Kaga

  7. Department of Pediatrics, Graduate School of Medicine, Hokkaido University, Kita-15, Nishi-7, Kita-ku, 060-8638, Sapporo, Japan

    Atsuhito Takeda

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  1. Ko Motoi
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Contributions

K.M. and H.I. had full access to all study data and take full responsibility for the integrity of the data and the accuracy of the data analysis. S.T., S.I., Y.T., H.A., K.N., M.M., M.N., S.Y., H.N., S.K., A.T., and T.A. substantially contributed to the study design, data analysis and interpretation, and writing and review of the manuscript.

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Correspondence to Hiroyuki Iwano.

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All authors have no conflicts of interest to disclose in relation to the present study.

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Motoi, K., Iwano, H., Tsuneta, S. et al. Impact of right ventricular stiffness on discordance between hemodynamic parameter and regurgitant volume in patients with pulmonary regurgitation. Int J Cardiovasc Imaging 39, 1133–1142 (2023). https://doi.org/10.1007/s10554-023-02825-x

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