Abstract
Background
Although there are robust data about the pathophysiology and prognostic implications
of left ventricular (LV) systolic dysfunction in patients with acquired heart disease,
similar prognostic data about LV systolic dysfunction are sparse in the tetralogy
of Fallot (TOF) population. The purpose of this study was to perform a meta-analysis
of all studies that assessed the relationship between LV ejection fraction (LVEF)
and cardiovascular adverse events (CAEs) defined as death, aborted sudden death, or
sustained ventricular tachycardia.
Methods
We used random-effects models to calculate hazard ratios (HRs) and 95% confidence
intervals (CIs).
Results
Of the 1,809 citations, 7 studies with 2,854 patients (age 28 ± 4 years) were included.
During 5.6 ± 3.4 years' follow-up, there were 82 deaths, 17 aborted sudden cardiac
deaths, and 56 sustained ventricular tachycardia events. Overall, CAEs occurred in
5.1% (144 patients). As a continuous variable, LVEF was a predictor of CAE (HR 1.29,
95% CI, 1.09-1.53, P = 0.001) per 5% decrease in LVEF. Similarly, LVEF < 40% was also a predictor of CAE
(HR 3.22, 95% CI, 2.16-4.80, P < 0.001).
Conclusions
LV systolic dysfunction was an independent predictor of CAE, and we observed a 30%
increase in the risk of CAE for every 5% decrease in LVEF, and a 3-fold increase in
the risk of CAE in patients with LVEF <40% compared with other patients. These findings
underscore the importance of incorporating LV systolic function in clinical risk stratification
of patients with TOF and the need to explore new treatment options to address this
problem.
Résumé
Contexte
Bien que l’on dispose de données solides sur la physiopathologie de la dysfonction
systolique ventriculaire gauche (VG) et sur ses répercussions sur le pronostic des
patients présentant une maladie cardiaque acquise, de telles données sur le pronostic
associé à la dysfonction systolique VG chez les patients présentant une tétralogie
de Fallot sont rares. La présente étude consiste en une méta-analyse de toutes les
études qui ont évalué la relation entre la fraction d’éjection VG (FEVG) et les événements
cardiovasculaires indésirables (ECI) que sont le décès, la mort cardiaque subite avortée
et la tachycardie ventriculaire soutenue.
Méthodologie
Nous avons utilisé des modèles à effets aléatoires pour calculer les rapports des
risques instantanés (RRI) et les intervalles de confiance (IC) à 95 %.
Résultats
Des 1 809 publications trouvées, 7 études portant sur un nombre total de 2 854 patients
(âge : 28 ± 4 ans) ont été retenues. Au cours de la période de suivi de 5,6 ± 3,4
ans, 82 décès, 17 morts cardiaques subites avortées et 56 cas de tachycardie ventriculaire
soutenue ont été relevés. Dans l’ensemble, des ECI sont survenus chez 5,1 % (144)
des patients. En tant que variable continue, la FEVG était un prédicteur d’ECI (RRI
de 1,29; IC à 95 % : de 1,09 à 1,53; p = 0,001), pour chaque diminution de 5 % de la FEVG. De même, une FEVG < 40 % était
aussi un prédicteur d’ECI (RRI de 3,22; IC à 95 % : de 2,16 à 4,80; p < 0,001).
Conclusions
La dysfonction systolique VG était un prédicteur indépendant d’ECI; nous avons observé
une hausse de 30 % du risque d’ECI pour chaque diminution de 5 % de la FEVG, et un
risque d’ECI trois fois plus élevé chez les patients présentant une FEVG < 40 % que
chez les autres patients. Ces constatations font ressortir l’importance de tenir compte
de la fonction systolique VG dans la stratification du risque clinique chez les patients
présentant une tétralogie de Fallot, ainsi que la nécessité d’explorer de nouvelles
options thérapeutiques pour résoudre ce problème.
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References
- Preoperative thresholds for mid-to-late haemodynamic and clinical outcomes after pulmonary valve replacement in tetralogy of Fallot.Eur Heart J. 2016; 37: 829-835
- Preoperative thresholds for pulmonary valve replacement in patients with corrected tetralogy of Fallot using cardiovascular magnetic resonance.Circulation. 2007; 116: 545-551
- Progressive right ventricular enlargement due to pulmonary regurgitation: clinical characteristics of a “low-risk” group.Am Heart J. 2018; 201: 136-140
- Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction.J Am Coll Cardiol. 2002; 40: 2044-2052
- 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2013; 62: e147-e239
- 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.J Am Coll Cardiol. 2019; 73: 1494-1563
- ESC Guidelines for the management of grown-up congenital heart disease (new version 2010).Eur Heart J. 2010; 31: 2915-2957
- Preoperative predictors of death and sustained ventricular tachycardia after pulmonary valve replacement in patients with repaired tetralogy of Fallot enrolled in the INDICATOR cohort.Circulation. 2018; 138: 2106-2115
- Contemporary predictors of death and sustained ventricular tachycardia in patients with repaired tetralogy of Fallot enrolled in the INDICATOR cohort.Heart. 2014; 100: 247-253
- NT-proBNP indicates left ventricular impairment and adverse clinical outcome in patients with tetralogy of Fallot and pulmonary regurgitation.Can J Cardiol. 2016; 32: 1247e29-1247e36
- Myocardial deformation parameters predict outcome in patients with repaired tetralogy of Fallot.Heart. 2016; 102: 209-215
- Value of cardiovascular magnetic resonance imaging in noninvasive risk stratification in tetralogy of Fallot.JAMA Cardiol. 2017; 2: 678-683
- Ventricular size and function assessed by cardiac MRI predict major adverse clinical outcomes late after tetralogy of Fallot repair.Heart. 2008; 94: 211-216
- Left ventricular longitudinal function predicts life-threatening ventricular arrhythmia and death in adults with repaired tetralogy of Fallot.Circulation. 2012; 125: 2440-2446
- A suggestion for quality assessment in systematic reviews of observational studies in nutritional epidemiology.Epidemiol Health. 2016; 38e2016014
- Effects of regional dysfunction and late gadolinium enhancement on global right ventricular function and exercise capacity in patients with repaired tetralogy of Fallot.Circulation. 2009; 119: 1370-1377
- Ventricular fibrosis suggested by cardiovascular magnetic resonance in adults with repaired tetralogy of fallot and its relationship to adverse markers of clinical outcome.Circulation. 2006; 113: 405-413
- Repaired tetralogy of Fallot: the roles of cardiovascular magnetic resonance in evaluating pathophysiology and for pulmonary valve replacement decision support.J Cardiovasc Magn Reson. 2011; 13: 9
- N Engl J Med.. 1993; 329: 593-599
- Ischemic myocardial injury during cardiopulmonary bypass surgery.Am Heart J. 1973; 85: 167-176
- Pulmonary valve replacement after operative repair of tetralogy of Fallot: meta-analysis and meta-regression of 3,118 patients from 48 studies.J Am Coll Cardiol. 2013; 62: 2227-2243
- 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America.J Am Coll Cardiol. 2017; 70: 776-803
- 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) developed with the special contribution of the Heart Failure Association (HFA) of the ESC.Eur Heart J. 2016; 37: 2129-2200
- Angiotensin-neprilysin inhibition versus enalapril in heart failure.N Engl J Med. 2014; 371: 993-1004
Article info
Publication history
Published online: August 08, 2019
Accepted:
July 27,
2019
Received:
May 20,
2019
Footnotes
See page 1789 for disclosure information.
See editorial by Wald and Oechslin, pages 1623--1625 of this issue.
Identification
Copyright
© 2019 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
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Access this article on ScienceDirectLinked Article
- ErratumCanadian Journal of CardiologyVol. 36Issue 11
- Looking to the Left to Get It Right: Left Ventricular Systolic Dysfunction and Risk Stratification Late After Tetralogy of Fallot RepairCanadian Journal of CardiologyVol. 35Issue 12
- PreviewMuch of the tetralogy of Fallot (TOF) story has been told from the perspective of the right heart. Embryologically, TOF develops as a right heart obstructive lesion arising secondary to anterior and superior deviation of the infundibular septum. Consequently, the anatomic substrate at birth, surgical repair in early childhood, and sequelae in later life are determined by early development and subsequent integrity of the right ventricular outflow tract (RVOT), pulmonary valve, and pulmonary arteries.
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