Reduced Right Ventricular Fractional Area Change, Strain, and Strain Rate before Bidirectional Cavopulmonary Anastomosis is Associated with Medium-Term Mortality for Children with Hypoplastic Left Heart Syndrome

Lin, Lily; Conway, Jennifer; Alvarez, Silvia; Goot, Benjamin H.; Serrano-Lomelin, Jesús; Colen, Timothy; Tham, Edythe B; Kutty, Shelby; Li, Ling; Khoo, Nee Scze

doi:10.1016/j.echo.2018.02.001

Cited by 32 publications

(17 citation statements)

References 43 publications

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“…Preoperative RV fractional area change was as a predictor but ranked lower than the pre-operative RV global longitudinal strain. This is likely due to the fact that deformation parameters, such as strain, are more sensitive to detect subclinical changes in function before overt changes can be seen with geometric or volumetric methods, such as fractional area change or ejection fraction, as shown in infants with single right ventricles and adults after heart transplant (34,35). While qualitative RV systolic function may be seemingly preserved pre-operatively, significant pre-operative RV remodeling with hypertrophy and subclinical dysfunction with altered myocardial deformation may occur and therefore, quantitative pre-operative assessment is important.…”

Section: Discussionmentioning

confidence: 99%

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

Faerber

Huang

Zhang

et al. 2021

Front. Cardiovasc. Med.

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Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair.Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication.Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models.Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.

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Section: Discussionmentioning

confidence: 99%

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

Faerber

Huang

Zhang

et al. 2021

Front. Cardiovasc. Med.

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“…As a paired advantage, in-HIP facilitated the internal coordination for unplanned interventions, with minimal impact on daily scheduling. The [15] awareness of resource utilization for in-HIP prompted anticipation of Norwood stage-two whenever feasible. Cardiac catheterization was routinely planned around months of age and followed by Norwood stage-two around the age of months (mean 138±9 days).…”

Section: Discussionmentioning

confidence: 99%

“…Recently speckle-tracking echocardiography has been shown to be a reliable technique in the evaluation of RV deformation without any geometric assumption [14]. Moreover, using myocardial deformation parameters, RV function can be assessed without the influence of acute preload changes [15]. Some studies [14][15][16] have used speckle-tracking analysis to estimate RV performance in HLHS, nevertheless its correlation with clinical outcome has not been clearly elucidated.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, using myocardial deformation parameters, RV function can be assessed without the influence of acute preload changes [15]. Some studies [14][15][16] have used speckle-tracking analysis to estimate RV performance in HLHS, nevertheless its correlation with clinical outcome has not been clearly elucidated. This study indicates that a LS of > 8.7% at onemonth after Norwood stage-one operation compared with basal pre-Norwood value is a powerful predictor of Norwood failure, defined as the combined outcome of death or transplantation during surgical staging.…”

Section: Discussionmentioning

confidence: 99%

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In-hospital interstage improves interstage survival after the Norwood stage 1 operation

Michielon

Salvo

Fraisse

et al. 2020

European Journal of Cardio-Thoracic Surgery

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OBJECTIVES The interstage mortality rate after a Norwood stage 1 operation remains 12–20% in current series. In-hospital interstage facilitates escalation of care, possibly improving outcome. METHODS A retrospective study was designed for hypoplastic left heart syndrome (HLHS) and HLHS variants, offering an in-hospital stay after the Norwood operation until the completion of stage 2. Daily and weekly examinations were conducted systematically, including two-dimensional and speckle-tracking echocardiography. Primary end points included aggregate survival until the completion of stage 2 and interstage freedom from escalation of care. Moreover, we calculated the sensitivity and specificity of speckle-tracking echocardiographic myocardial deformation in predicting death/transplant after the Norwood procedure. RESULTS Between 2015 and 2019, 33 neonates with HLHS (24) or HLHS variants (9) underwent Norwood stage 1 (31) or hybrid palliation followed by a comprehensive stage 2 operation (2). Stage 1 Norwood–Sano was preferred in 18 (54.5%) neonates; the classic Norwood with Blalock–Taussig shunt was performed in 13 (39.4%) neonates. The Norwood stage 1 30-day mortality rate was 6.2%. The in-hospital interstage strategy was implemented after Norwood stage 1 with a 3.4% interstage mortality rate. The aggregate Norwood stage 1 and interstage Kaplan–Meier survival rate was 90.6 ± 5.2%. Escalation of care was necessary for 5 (17.2%) patients at 2.5 ± 1.2 months during the interstage for compromising atrial arrhythmias (2), Sano-shunt stenosis (1) and pneumonia requiring a high-frequency oscillator (2); there were no deaths. A bidirectional Glenn (25) or a comprehensive-Norwood stage 2 (2) was completed in 27 patients at 4.7 ± 1.2 months with a 92.6% survival rate. The overall Kaplan–Meier survival rate is 80.9 ± 7.0% at 4.3 years (mean 25.3 ± 15.7 months). An 8.7% Δ longitudinal strain 30 days after Norwood stage 1 had 100% sensitivity and 81% specificity for death/transplant. CONCLUSIONS In-hospital interstage facilitates escalation of care, which seems efficacious in reducing interstage Norwood deaths. A significant reduction of longitudinal strain after Norwood stage 1 is a strong predictor of poor outcome.

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“…1,2 Longitudinal studies demonstrate a decrease in strain over time as a particularly important marker of risk in young patients. 3,4 Inspection of the strain values reported in the hypoplastic left heart syndrome population reveals differences across patient age, palliation stage or strategy, 1,2,[5][6][7][8] and anatomic subtype 9,10 using either vendor-specific software (ie, GE EchoPac (EP), Philips 11,12 ) or vendor-independent software (ie, TomTec (TT)). 4,10 Several software-related factors influence deformation quantification and can be sources of variation and inconsistencies.…”

mentioning

confidence: 99%

Single systemic right ventricle longitudinal strain: Intravendor reproducibility and intervendor agreement in children

et al. 2021

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Longitudinal strain derived from grayscale 2D speckle-tracking echocardiography is emerging as a useful clinical tool in the assessment of single, systemic right ventricle (sRV) function, as it provides an objective and reproducible measurement of myocardial performance. In pediatric patients with single right ventricles, there are no established thresholds that define abnormal, though longitudinal strain that is more negative (or higher in absolute number) reflects greater myocardial motion inferred as better function.

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Reduced Right Ventricular Fractional Area Change, Strain, and Strain Rate before Bidirectional Cavopulmonary Anastomosis is Associated with Medium-Term Mortality for Children with Hypoplastic Left Heart Syndrome

Cited by 32 publications

References 43 publications

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach

In-hospital interstage improves interstage survival after the Norwood stage 1 operation

Single systemic right ventricle longitudinal strain: Intravendor reproducibility and intervendor agreement in children

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