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. 2022 Jul 14:9:929470.
doi: 10.3389/fcvm.2022.929470. eCollection 2022.

Abnormal Diastolic Hemodynamic Forces: A Link Between Right Ventricular Wall Motion, Intracardiac Flow, and Pulmonary Regurgitation in Repaired Tetralogy of Fallot

Yue-Hin Loke  1   2 , Francesco Capuano  3 , Sarah Kollar  1 , Merih Cibis  4 , Pieter Kitslaar  4 , Elias Balaras  5 , Johan H C Reiber  4 , Gianni Pedrizzetti  6   7 , Laura Olivieri  2   8
Affiliations

Abnormal Diastolic Hemodynamic Forces: A Link Between Right Ventricular Wall Motion, Intracardiac Flow, and Pulmonary Regurgitation in Repaired Tetralogy of Fallot

Yue-Hin Loke et al. Front Cardiovasc Med. .

Abstract

Background and objective: The effect of chronic pulmonary regurgitation (PR) on right ventricular (RV) dysfunction in repaired Tetralogy of Fallot (RTOF) patients is well recognized by cardiac magnetic resonance (CMR). However, the link between RV wall motion, intracardiac flow and PR has not been established. Hemodynamic force (HDF) represents the global force exchanged between intracardiac blood volume and endocardium, measurable by 4D flow or by a novel mathematical model of wall motion. In our study, we used this novel methodology to derive HDF in a cohort of RTOF patients, exclusively using routine CMR imaging.

Methods: RTOF patients and controls with CMR imaging were retrospectively included. Three-dimensional (3D) models of RV were segmented, including RV outflow tract (RVOT). Feature-tracking software (QStrain 2.0, Medis Medical Imaging Systems, Leiden, Netherlands) captured endocardial contours from long/short-axis cine and used to reconstruct RV wall motion. A global HDF vector was computed from the moving surface, then decomposed into amplitude/impulse of three directional components based on reference (Apical-to-Basal, Septal-to-Free Wall and Diaphragm-to-RVOT direction). HDF were compared and correlated against CMR and exercise stress test parameters. A subset of RTOF patients had 4D flow that was used to derive vorticity (for correlation) and HDF (for comparison against cine method).

Results: 68 RTOF patients and 20 controls were included. RTOF patients had increased diastolic HDF amplitude in all three directions (p<0.05). PR% correlated with Diaphragm-RVOT HDF amplitude/impulse (r = 0.578, p<0.0001, r = 0.508, p < 0.0001, respectively). RV ejection fraction modestly correlated with global HDF amplitude (r = 0.2916, p = 0.031). VO2-max correlated with Septal-to-Free Wall HDF impulse (r = 0.536, p = 0.007). Diaphragm-to-RVOT HDF correlated with RVOT vorticity (r = 0.4997, p = 0.001). There was no significant measurement bias between Cine-derived HDF and 4D flow-derived HDF by Bland-Altman analysis.

Conclusion: RTOF patients have abnormal diastolic HDF that is correlated to PR, RV function, exercise capacity and vorticity. HDF can be derived from conventional cine, and is a potential link between RV wall motion and intracardiac flow from PR in RTOF patients.

Keywords: 4D flow; Tetralogy of Fallot; cardiac magnetic resonance; feature tracking; hemodynamic force.

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Conflict of interest statement

MC, PK, and JR were employed by Medis Medical Imaging Systems. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

FIGURE 1
FIGURE 1
Overall methodology of using three-dimensional (3D) modeling and feature tracking of cine imaging to derive hemodynamic forces (HDF). The planes of the tricuspid valve (TV) and pulmonic valve (PV) were also delineated prior to kinematic reconstruction.
FIGURE 2
FIGURE 2
Decomposition of hemodynamic forces into three components for analysis, including the Diaphragm-to-Right ventricular outflow tract (RVOT) axis, Septal-to-Free Wall axis and Apical-to-Basal axis.
FIGURE 3
FIGURE 3
Comparison of diastolic hemodynamic force (A) amplitude and (B) impulse, between repaired Tetralogy of Fallot (RTOF) patients and normal controls. **p < 0.01; ***p < 0.001.
FIGURE 4
FIGURE 4
(A) Hemodynamic force (HDF) comparison between one representative control case and representative repaired Tetralogy of Fallot (RTOF). In normal control, HDF is predominantly in the Apical-to-Basal axis. In RTOF, the HDF is distributed toward both the Diaphragm-RVOT axis and Apical-to-Basal axis during early filling and persists through diastasis. (B) Hemodynamic force comparison of mean values between RTOF patient cohort and control cohort. The same patterns described in panel (A) is also noted across the cohort.
FIGURE 5
FIGURE 5
Qualitative comparison between one representative control case and representative repaired Tetralogy of Fallot (RTOF). In normal control, there is alignment of the global hemodynamic force (HDF) vector in the Apical-to-Basal axis. In RTOF, the HDF is distributed toward both the Diaphragm-RVOT axis and Apical-to-Basal axis during early filling and persists through diastasis.
FIGURE 6
FIGURE 6
Correlation of Diaphragm-to-RVOT HDF and Apical-to-basal HDF amplitude with pulmonary insufficiency in repaired tetralogy of fallot (RTOF) patients.
FIGURE 7
FIGURE 7
Correlation of diastolic HDF (cine-derived) with intracardiac vorticity (4D flow-derived).
FIGURE 8
FIGURE 8
Hemodynamic force (4D flow-derived vs. cine-derived) comparison of mean values in the RTOF cohort over the cardiac cycle. Timepoints denoted by * indicate statistical difference (p < 0.05) between the 4D flow-derived parameters and cine-derived parameters. In general, there is underestimation of systolic hemodynamic force in the Diaphragm-to-RVOT axis using the cine-derived methodology.
FIGURE 9
FIGURE 9
Bland-Altman Analysis between 4D flow-derived vs. cine-derived HDF.
See this image and copyright information in PMC

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