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J Thorac Cardiovasc Surg 2007;133:1656-1658
© 2007 The American Association for Thoracic Surgery

Brief Communication

Reduced regional right ventricular wall motion after transventricular repair of tetralogy of Fallot

^a Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan
^b Department of Pediatrics, Mie University Graduate School of Medicine, Mie, Japan.

Received for publication February 19, 2006; accepted for publication March 5, 2006.

^_* Address for reprints: Shin Takabayashi, MD, Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174, Edobashi, Tsu, Mie 514-8507, Japan. (Email: shin1111{at}clin.medic.mie-u.ac.jp).

During intracardiac repair of tetralogy of Fallot (TOF), a larger right ventriculotomy provides better exposure of ventricular structures. However, right ventricular (RV) function is impaired after ventriculotomy, and a previous report suggests that ventriculotomy reduces regional wall motion around the RV incision.¹ To investigate the impact of right ventriculotomy on regional RV wall function, we used postoperative lateral RV angiocardiography to compare segmental fractional shortening (FS) after transventricular and transpulmonary–transatrial TOF repair.

Clinical Summary

We studied 28 consecutive patients who underwent TOF repair between 1994 and 1998. They were divided into two groups: the first 14 patients underwent transventricular repair (group V) and the other 14 underwent transatrial–transpulmonary repair (group A). The mean age (2.9 vs 2.6 years), weight (13.0 vs 11.4 kg) and preoperative RV function were not significantly different between group V and group A. Three patients in group V had undergone a prior operation (systemic–pulmonary shunt, 2; Brock, 1), and 1 patient in group A had undergone a systemic–pulmonary shunt. A transannular patch repair was performed in 9 patients in each group. Definitive repair by ventricular septal defect closure was performed through a 15- to 20-mm RV incision in group V. A limited RV incision (<10 mm) was performed in the patients in group A who underwent a transannular patch repair. We performed muscle resection of the RV outflow tract (except the ventricular septum) in both groups.

There were no postoperative deaths. Echocardiography at the time of discharge showed pulmonary stenosis (>30 mm Hg) in 2 patients in each group and pulmonary insufficiency (>moderate) in 3 patients in group V and 2 patients in group A.

Angiocardiography (median 1.2 months after the operation) showed that although the RV end-diastolic volume by the Simpson method was similar in group V and group A (93 vs 86 mL/m²), the RV ejection fraction was lower in group V than in group A (48% ± 9% vs 63% ± 10%: P < .05), and the RV end-diastolic pressure was higher in group V than in group A (9.3 vs 4.3 mm Hg; P < .05). To investigate the postoperative regional RV wall motion, we used the centerline method to calculate segmental FS on lateral RV angiocardiography.² We assessed 5 RV areas, determining the mean value of each 20/100 of segmental FS (anterosuperior, 80-100; anteroinferior, 60-80; apex, 40-60; posteroinferior, 20-40; and posterosuperior, 0–20), and compared regional RV wall motion between group V and group A (Figure 1). Regional wall motion of the anterosuperior area (the site of ventriculotomy) was significantly lower in group V than in group A (0.3% ± 0.6% vs 2.0% ± 0.6%; P < .01). Although wall motion of the apex (4.6% ± 1.6% vs 5.6% ± 1.8%) and posteroinferior area (3.1% ± 2.2% vs 3.2% ± 2.2%) was similar in group V and group A, wall motion of the anteroinferior (2.4% ± 1.0% vs 3.7% ± 1.0%; P < .05) and posterosuperior areas (0.8% ± 0.8% vs 2.1% ± 1.4%; P < .05) was significantly lower in group V than group A.

View larger version (33K): [in this window] [in a new window]   Figure 1. Schema of regional wall motion assessed by the centerline method, and comparison of regional right ventricular wall motion between group V and group A. FS, Fractional shortening, **P < .01, *P < .05.

Although the right ventriculotomy used for TOF repair inevitably impairs the postoperative RV function to some degree, impaired regional RV function could not be clearly detected by early³ or late⁴ clinical outcomes, and detailed analysis of postoperative regional RV function after ventriculotomy has not been well described.

Our analysis of segmental FS using the centerline method showed that RV wall motion of the anteroinferior and posterosuperior areas, as well as the ventriculotomy site, was more reduced in the transventricular repair group than the transatrial–transpulmonary repair group. Although our study is not a quantitative analysis because the lateral view of the right ventriculography was not expressed as 3-dimensional RV function, these results suggest that reduction of the whole RV function (ejection fraction and end-diastolic pressure) would be brought about by reduction of regional RV function at the site of the ventriculotomy, as well as the surrounding areas of the right ventricle. The cause of reduced RV wall motion around the ventriculotomy site is multifactorial. One of the mechanisms involved is the architecture of the cardiac muscle fibers in the TOF heart. The superficial muscle layer has a more oblique orientation in the TOF heart than the normal heart, and a middle horizontal layer has been found in the RV wall that does not exist in the normal heart.⁵ These may play an important role in postoperative regional RV contractility around the ventriculotomy.

Reduction of regional RV function can occur around the ventriculotomy site after TOF repair. So that postoperative RV function will be preserved, ventriculotomy should be minimal and performed only if necessary.

References

1. Miura T, Nakano S, Shimazaki Y, Kobayashi J, Hirose H, Sano T, et al. Evaluation of right ventricular function by regional wall motion analysis in patients after correction of tetralogy of Fallot: comparison of transventricular and nontransventricular repairs. J Thorac Cardiovasc Surg 1992;104:917-923.[Abstract]
   
2. Sheehan FH, Bolson EL, Dodge HT, Mathey DG, Schofer J, Woo HW. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation 1986;74:293-305.[Abstract/Free Full Text]
   
3. Alexiou C, Chen Q, Galogavrou M, Gnanapragasam J, Salmon AP, Keeton BR, et al. Repair of tetralogy of Fallot in infancy with a transventricular or a transatrial approach. Eur J Cardiothorac Surg 2002;22:174-183.[Abstract/Free Full Text]
   
4. d’Udekem Y, Ovaert C, Grandjean F, Gerin V, Cailteux M, Shango-Lody P, et al. Tetralogy of Fallot: transannular and right ventricular patching equally affect late functional status. Circulation 2000;102(Suppl 3):III116-III122.[Medline]
   
5. Sanchez-Quintana D, Anderson RH, Ho SY. Ventricular myoarchitecture in tetralogy of Fallot. Heart 1996;76:280-286.[Abstract/Free Full Text]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shin Takabayashi Hideto Shimpo Koji Onoda Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takabayashi, S. Articles by Mitani, Y. Search for Related Content PubMed PubMed Citation Articles by Takabayashi, S. Articles by Mitani, Y. Related Collections Congenital - cyanotic