Long-term ventricular performance after intra-atrial correction of transposition: left ventricular filling is the major limitation

Abstract

Objective: To establish the incidence of systolic and diastolic dysfunction of the right and left ventricle in a large cohort of patients after Mustard or Senning operations and to assess changes in the incidence on long term follow up.

Design: Postoperative case-control study using radionuclide ventriculography. Ejection fractions, peak filling rates, rapid filling periods and fractions, slow filling periods and fractions, and atrial contraction periods and fractions were studied.

Setting: Tertiary care centre, ambulatory and hospital inpatient care.

Patients: A convenience sample of 153 patients studied at median age of 6.9 years (median 4.4 years after surgery). In 99 cases another study was available at a median age of 15.3 years (median 13 years after surgery and 8.8 years after the first study).

Results: Respective incidences of dysfunction in the first and the second study were as follows: ejection fraction-right ventricle 7.8% and 8.1%, left ventricle 7.2% and 10.1%: peak filling rate-right ventricle 0% and 4.2%, left ventricle 14.3% and 29.5% (p < 0.05); rapid filling period-right ventricle 18.3% and 11.6%, left ventricle 30.2% and 30.5%; slow filling period-right ventricle 4.8% and 3.2%; left ventricle 11.9% and 23.2%; atrial contraction period-right ventricle 0.8% and 4.2%, left ventricle 15.1% and 26.3%; rapid filling fraction-right ventricle both 0%, left ventricle 82.5% and 79.0%; slow filling fraction-right ventricle 0.8% and 4.2%, left ventricle 37.3% and 30.5%; atrial contraction fraction-right ventricle both 0%, left ventricle 79.4% and 71.6%.

Conclusions: The incidence of systolic ventricular dysfunction is 8% (right ventricle) and 10% (left ventricle) 13 years after surgery, without a significant increase over the eight year follow up. Diastolic filling is abnormal in up to 80% of patients and left ventricular peak filling rate deteriorates with time.

Figure 1

Calculation of the variables (see text). ACF, atrial contraction fraction; ACP, atrial contraction period; DV, change in velocity; EDV, end diastolic volume; ESV, end systolic volume; RFF, rapid filling fraction; RFP, rapid filling period; SFF, slow filling fraction; SFP, slow filling period; SV, stroke volume.

Figure 2

Comparison of volume curves before and early after the surgery. Note changes in the left ventricular diastolic filling. TGA, transposition of the great arteries; Mustard, Mustard operation.

Figure 3

Actuarial probability of normal values. LVEF, left ventricular ejection fraction; LVPFR, left ventricular peak filling rate; LVRFF, left ventricular rapid filling fraction; RVEF, right ventricular ejection fraction.

Figure 4

M mode (left panel) and pulsed Doppler (right panel) findings after Senning procedure. In mid-diastole (arrows), the systemic venous atrium (SVA) is compressed by pressure from surrounding pulmonary venous atrium (PVA). This causes a decrease in left ventricular filling rate until the SVA reopens due to a pressure increase proximal to the narrowed segment. The filling rate then increases again, with only a small contribution from atrial contraction (arrowhead). See Discussion.