Functional assessment for congenital heart disease

Abstract

Significant improvement in survival of children with congenital cardiac malformations has resulted in an increasing population of adolescent and adult patients with congenital heart disease. Of the long-term cardiac problems, ventricular dysfunction remains an important issue of concern. Despite corrective or palliative repair of congenital heart lesions, the right ventricle, which may be the subpulmonary or systemic ventricular chamber, and the functional single ventricle are particularly vulnerable to functional impairment. Regular assessment of cardiac function constitutes an important aspect in the long-term follow up of patients with congenital heart disease. Echocardiography remains the most useful imaging modality for longitudinal monitoring of cardiac function. Conventional echocardiographic assessment has focused primarily on quantification of changes in ventricular size and blood flow velocities during the cardiac cycles. Advances in echocardiographic technologies including tissue Doppler imaging and speckle tracking echocardiography have enabled direct interrogation of myocardial deformation. In this review, the issues of ventricular dysfunction in congenital heart disease, conventional echocardiographic and novel myocardial deformation imaging techniques, and clinical applications of these techniques in the functional assessment of congenital heart disease are discussed.

Keywords: Congenital heart disease; Echocardiography, three-dimensional; Speckle tracking echocardiography; Tissue Doppler imaging; Ventricular function.

Fig. 1

Real-time three-dimensional echocardiographic analysis of left ventricular (LV) and right ventricular (RV) volumes. The regional time-volume curves of the 16 LV segments enable the assessment of LV mechanical dyssynchrony.

Fig. 2

Pulsed-Doppler echocardiography demonstrating antegrade diastolic flow in the main pulmonary artery during atrial systole.

Fig. 3

Tissue Doppler imaging with the curser at the right ventricular free wall-tricuspid annular junction. a: late diastolic myocardial velocity, e: early diastolic myocardial velocity, IVA: isovolumic acceleration, s: systolic myocardial velocity, Δt: time difference, Δv: velocity change.

Fig. 4

Two-dimensional speckle tracking echocardiography demonstrating the assessment of global left ventricular (LV) and right ventricular (RV) longitudinal strain from the four-chamber view, and LV circumferential and radial strain from the mid-LV short axis.

Fig. 5

Quantification of three-dimensional (3D) strain based on 3D speckle tracking echocardiographic assessment of the full volume 3D dataset acquired from the cardiac apex.

Fig. 6

Tissue Doppler strain imaging showing systemic right ventricular dyssynchrony in a patient after atrial switch operation for transposition of the great arteries as evidenced by differences of time to peak systolic strain right ventricular free wall and septal segments (A) compared to the similar timing in a healthy subject (B).

Fig. 7

Left panel: normal septal geometry in the healthy subject and distortion of septal geometry with compression of the subpulmonary left ventricle in a patient after atrial repair for complete transposition of the great arteries. Right panel: two-dimensional speckle tracking echocardiography enables deformation imaging of the subpulmonary left ventricle in patient as compared to the systemic left ventricle in a normal subject. TGA: transposition of the great arteries.