Abstract
Background
Predicting heart failure events in patients with a systemic right ventricle (sRV)
due to transposition of the great arteries (TGA) is important for timely intensification
of follow-up. This study assessed the value of strain compared with currently used
parameters as predictor for heart failure–free survival in patients with sRV.
Methods
In participants of a multicentre trial, speckle-tracking echocardiography (STE) was
performed to assess global longitudinal strain (GLS), mechanical dispersion (MD),
and postsystolic shortening (PSS). Cox regression was used to determine the association
of STE parameters with the combined end point of progression of heart failure and
death, compared with cardiovascular magnetic resonance (CMR) and computed tomography
(CT) derived parameters.
Results
Echocardiograms of 60 patients were analyzed (mean age 34 ± 11 years, 65% male, 35%
congenitally corrected TGA). Mean GLS was −13.5 ± 2.9%, median MD was 49 (interquartile
range [IQR] 30-76) ms, and 14 patients (23%) had PSS. During a median 8 (IQR 7-9)
years, 15 patients (25%) met the end point. GLS, MD, and PSS were all associated with
heart failure–free survival in univariable analysis. After correction for age, only
GLS (optimal cutoff > −10.5%) and CMR/CT-derived sRV ejection fraction (optimal cutoff
< 30%) remained associated with heart failure–free survival: hazard ratio (HR) 8.27,
95% confidence interval (CI) 2.50-27.41 (P < 0.001), and HR 4.34, 95% CI 1.48-12.74 (P = 0.007), respectively). Combining GLS and ejection fraction improved prediction,
with patients with both GLS > −10.5% and sRV ejection fraction < 30% at highest risk
(HR 19.69, 95% CI 4.90-79.13; P < 0.001).
Conclusions
The predictive value of GLS was similar to that of CMR/CT-derived ejection fraction.
The combination of GLS and ejection fraction identified patients at highest risk of
heart failure and death. Easily available STE parameters can be used to guide follow-up
intensity and can be integrated into future risk prediction scores.
Résumé
Contexte
La prévision des manifestations d’insuffisance cardiaque chez les patients présentant
un ventricule droit systémique (VDs) en raison d’une transposition des gros vaisseaux
(TGV) s’avère importante pour l’intensification du suivi en temps opportun. Cette
étude a permis d’évaluer la valeur de la déformation myocardique comme facteur prévisionnel
de survie sans insuffisance cardiaque par rapport aux paramètres actuellement utilisés
chez les patients présentant un VDs.
Méthodologie
Chez les participants d’un essai multicentrique, une échocardiographie de suivi des
marqueurs acoustiques (ESMA) a été réalisée afin d’évaluer la déformation longitudinale
globale (DLG), la dispersion mécanique (DM) et le raccourcissement postsystolique
(RPS). Le modèle de régression de Cox a servi à déterminer l’association des paramètres
d’ESMA et du paramètre d’évaluation regroupant la progression de l’insuffisance cardiaque
et le décès, comparativement à des paramètres d’imagerie par résonance magnétique
cardiovasculaire (IRMC) et de tomodensitométrie (TDM).
Résultats
Les échocardiogrammes de 60 patients (âge moyen de 34 ± 11 ans, 65 % de sexe masculin,
35 % présentant une transposition congénitalement corrigée des gros vaisseaux) ont
été analysés. La DLG moyenne était de -13,5 ± 2,9 % et la DM médiane, de 49 ms (intervalle
interquartile de 30-76 ms), et un RPS a été noté chez 14 patients (23 %). Sur une
période médiane de 8 ans (7-9 ans), le paramètre d’évaluation a été atteint chez 15
patients (25 %). La DLG, la DM et le RPS étaient tous associés à la survie sans insuffisance
cardiaque dans une analyse unidimensionnelle. Après correction pour tenir compte de
l’âge, seules la DLG (valeur seuil optimale > -10,5 %) et la fraction d’éjection du
VDs en IRMC/TDM (valeur seuil optimale < 30 %) sont demeurées associées à la survie
sans insuffisance cardiaque : rapport des risques instantanés (RRI) de 8,27 et de
4,34, intervalle de confiance (IC) à 95 % de 2,50-27,41 et de 1,48-12,74, p < 0,001 et p = 0,007, respectivement. La combinaison de la DLG et de la fraction d’éjection a
amélioré la valeur prévisionnelle; les patients les plus à risque présentaient une
DLG > -10,5 % et une fraction d’éjection du VDs < 30 % (RRI de 19,69, IC à 95 % de
4,90-79,13; p < 0,001).
Conclusions
La valeur prévisionnelle de la DLG a été similaire à celle de la fraction d’éjection
en IRMC/TDM. La combinaison de la DLG et de la fraction d’éjection a permis de cibler
les patients présentant le risque le plus élevé d’insuffisance cardiaque et de décès.
Des paramètres d’ESMA faciles à mesurer peuvent servir à déterminer le degré de suivi
nécessaire. Leur intégration aux scores de prévision du risque est envisageable à
l’avenir.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Canadian Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- The natural and unnatural history of the Mustard procedure: long-term outcome up to 40 years.Eur Heart J. 2014; 35: 1666-1674
- Long-term outcome after atrial correction for transposition of the great arteries.Heart. 2019; 105: 790-796
- Systemic right ventricular longitudinal strain is reduced in adults with transposition of the great arteries, relates to subpulmonary ventricular function, and predicts adverse clinical outcome.Am Heart J. 2012; 163: 859-866
- Right ventricular function with standard and speckle-tracking echocardiography and clinical events in adults with D-transposition of the great arteries post atrial switch.J Am Soc Echocardiogr. 2012; 25: 304-312
- Prediction of all-cause mortality from global longitudinal speckle strain: comparison with ejection fraction and wall motion scoring.Circ Cardiovasc Imaging. 2009; 2: 356-364
- Left ventricular global longitudinal strain (GLS) is a superior predictor of all-cause and cardiovascular mortality when compared to ejection fraction in advanced chronic kidney disease.PLoS One. 2015; 10e0127044
- Global longitudinal strain to predict mortality in patients with acute heart failure.J Am Coll Cardiol. 2018; 71: 1947-1957
- Incidence and characteristics of segmental postsystolic longitudinal shortening in normal, acutely ischemic, and scarred myocardium.J Am Soc Echocardiogr. 2003; 16: 415-423
- Strain echocardiography is related to fibrosis and ventricular arrhythmias in hypertrophic cardiomyopathy.Eur Heart J Cardiovasc Imaging. 2016; 17: 613-621
- Systemic right ventricular fibrosis detected by cardiovascular magnetic resonance is associated with clinical outcome, mainly new-onset atrial arrhythmia, in patients after atrial redirection surgery for transposition of the great arteries.Circ Cardiovasc Imaging. 2015; 8e002628
- Postsystolic shortening by speckle tracking echocardiography is an independent predictor of cardiovascular events and mortality in the general population.J Am Heart Assoc. 2018; 7e008367
- 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.Circulation. 2018; 139: e698-e800
- Effect of valsartan on systemic right ventricular function: a double-blind, randomized, placebo-controlled pilot trial.Circulation. 2013; 127: 322-330
- Rationale and design of a trial on the effect of angiotensin II receptor blockers on the function of the systemic right ventricle.Am Heart J. 2010; 160: 812-818
- Long-term clinical outcomes of valsartan in patients with a systemic right ventricle: follow-up of a multicenter randomized controlled trial.Int J Cardiol. 2019; 278: 84-87
- Right ventricular longitudinal strain reproducibility using vendor-dependent and vendor-independent software.J Am Soc Echocardiogr. 2018; 31: 721-732.e725
- Global longitudinal strain software upgrade: implications for intervendor consistency and longitudinal imaging studies.Arch Cardiovasc Dis. 2016; 109: 22-30
- Determination of best post-systolic shortening parameters on resting TTE for detection of left ventricular ischemic segments quantitatively confirmed by invasive fractional flow reserve.Int J Cardiol. 2016; 222: 27-30
- Prognostic value of plasma B-type natriuretic peptide in the long-term follow-up of patients with transposition of the great arteries with morphologic right systemic ventricle after atrial switch operation.Circ J. 2015; 79: 2677-2681
- Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries.Heart. 2005; 91: 652-656
- Right ventricular end-diastolic volume combined with peak systolic blood pressure during exercise identifies patients at risk for complications in adults with a systemic right ventricle.J Am Coll Cardiol. 2013; 62: 926-936
- Shrinkage methods enhanced the accuracy of parameter estimation using Cox models with small number of events.J Clin Epidemiol. 2013; 66: 743-751
- Physiological determinants of left ventricular mechanical dispersion: a 2-dimensional speckle tracking echocardiographic study in healthy volunteers.JACC Cardiovasc Imaging. 2018; 11: 650-651
- Myocardial fibrosis and its relation to adverse outcome in transposition of the great arteries with a systemic right ventricle.Int J Cardiol. 2018; 271: 60-65
- Myocardial ischaemia and post-systolic shortening.Heart. 2015; 101: 509-516
- Comparison of systemic right ventricular function in transposition of the great arteries after atrial switch and congenitally corrected transposition of the great arteries.Int J Cardiovasc Imaging. 2017; 33: 1993-2001
- Dyssynchrony, contraction efficiency and regional function with apical and nonapical RV pacing.Heart. 2015; 101: 600-608
- Longitudinal strain of systemic right ventricle correlates with exercise capacity in adult with transposition of the great arteries after atrial switch.Int J Cardiol. 2016; 217: 28-34
- Global longitudinal strain may identify preserved systolic function of the systemic right ventricle.Can J Cardiol. 2015; 31: 760-766
- Quantitative assessment of systolic right ventricular function using myocardial deformation in patients with a systemic right ventricle.Eur Heart J Cardiovasc Imaging. 2015; 16: 380-388
- Exploring the prognostic value of novel markers in adults with a systemic right ventricle.J Am Heart Assoc. 2019; 8e013745
- NT-proBNP predicts mortality in adults with transposition of the great arteries late after Mustard or Senning correction.Congenit Heart Dis. 2017; 12: 448-457
- Aerobic training in adults after atrial switch procedure for transposition of the great arteries improves exercise capacity without impairing systemic right ventricular function.Int J Cardiol. 2013; 170: 24-29
- Declining cardiopulmonary exercise capacity is not associated with worsening systolic systemic ventricular dysfunction in adults with transposition of great arteries after atrial switch operation.Congenit Heart Dis. 2014; 9: 259-265
- Mechanical dispersion and global longitudinal strain by speckle tracking echocardiography: predictors of appropriate implantable cardioverter defibrillator therapy in hypertrophic cardiomyopathy.Echocardiography. 2017; 34: 835-842
- Multimodality comparison of quantitative volumetric analysis of the right ventricle.JACC Cardiovasc Imaging. 2010; 3: 10-18
- Contraction pattern of the systemic right ventricle shift from longitudinal to circumferential shortening and absent global ventricular torsion.J Am Coll Cardiol. 2007; 49: 2450-2456
- Left ventricular global strain analysis by two-dimensional speckle-tracking echocardiography: the learning curve.J Am Soc Echocardiogr. 2017; 30: 1081-1090
Article info
Publication history
Published online: December 17, 2019
Accepted:
December 10,
2019
Received:
August 7,
2019
Footnotes
See editorial by Chen-Tournoux et al., pages 1341—1343 of this issue.
See page 1532 for disclosure information.
Identification
Copyright
© 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Echocardiographic Strain Imaging in the Systemic Right Ventricle: Early Clue for Late DecompensationCanadian Journal of CardiologyVol. 36Issue 9
- PreviewRight ventricular (RV) systolic function is increasingly appreciated as a powerful determinant of patient outcome in a variety of conditions, including myocardial infarction, heart failure, valvular heart disease, pulmonary hypertension, and congenital heart disease.1,2 Perhaps no other situation highlights the importance of RV systolic function more evidently than systemic RV (SRV), where the morphologic RV must support the systemic circulation. SRV occurs in mainly 3 congenital heart conditions: transposition of the great arteries corrected by a Mustard or Senning operation (TGA-MS), congenitally corrected TGA (CCTGA), and some Fontan patients.
- Full-Text
- Preview
