Mid Term Evaluation of Patients Undergoing Surgery for Tetralogy of Fallot with 24 Hour Rhythm Holter and Cardiopulmonary Exercise Testing

Abstract

Objective: This study aimed to obtain mid-term evaluation of exercise capacity and arrhythmias with cardiopulmonary exercise testing (CPET) and 24-hour rhythm Holter in Tetralogy of Fallot (TOF) patients who underwent surgery. Materials and Methods: The study group consisted of patients over 6 years of age who had undergone complete correction surgery for TOF, while the control group consisted of healthy children of a similar age group who did not have any heart disease. Echocardiography, 24-hour Holter monitoring and CPET were applied to both groups. Results: Study group included 14 patients who were operated on due to TOF and 9 healthy children as the control group. During echocardiographic examination; aortic diameter, pulmonary annulus, right ventricular (RV) systolic and diastolic areas were found to be significantly larger in the patient group (p=0.044, p=0.017, p=0.05, p=0.012 respectively). Myocardial performance index (Tei index-MPI) calculated from mitral and tricuspid valve annulus was found to be significantly higher in the patient group (p=0.05 for both). During CPET, stroke volume and VO2max levels were significantly smaller in patients (p=0.004, p=0.044 respectively). Conclusion: Although operated TOF patients are asymptomatic in the mid-term, the exercise capacity in these patients is lower than in healthy individuals and this decrease is related to right ventricular size and dysfunction.

Keywords

• Tetralogy of Fallot
• Exercise Capacity
• Arrhythmia

Project Number

09.2016.216

Ethical Statement

I have obtained the data and information presented in this study within academic and ethical rules, I have presented all information, documents, evaluations and results in accordance with the rules of scientific ethics and morality, that I have cited all of the works I have used in this study with appropriate attribution, I declare that I have not made any changes in the data used and that the study is original. Otherwise, I declare that I accept all loss of rights that may arise against me.

Fallot Tetralojisi Nedeni ile Ameliyat Edilen Hastaların 24 Saatlik Ritim Holter ve Kardiyopulmoner Egzersiz Testi ile Orta Dönemde Değerlendirilmesi

Abstract

Amaç: Bu çalışmada ameliyat edilen Fallot tetralojisi (FT) hastalarında egzersiz kapasitesinin ve aritmilerin kardiyopulmoner egzersiz testi (KPET) ve 24 saatlik ritim Holter ile orta dönemde değerlendirilmesi amaçlanmıştır. Gereç ve yöntemler: Çalışma grubu FT nedeniyle tam düzeltme ameliyatı geçirmiş 6 yaş üzerindeki hastalardan, kontrol grubu ise benzer yaş grubundaki herhangi bir kalp hastalığına sahip olmayan sağlıklı çocuklardan oluşturuldu. Her iki gruba ekokardiyografi, 24 saatlik Holter monitorizasyonu ve KPET uygulandı. Bulgular: Çalışmaya FT nedeniyle opere edilmiş 14 hasta ve kontrol grubu olarak da 9 sağlıklı çocuk alınmıştır. Hasta grubunda ekokardiyografik olarak aort çapı, pulmoner anulus, sağ ventrikül sistolik ve diyastolik alanları anlamlı olarak geniş bulunmuştur. (Sırasıyla p=0,044, p=0,017, p=0,05, p=0,012) Mitral ve triküspit kapak anuluslarından hesaplanan miyokardiyal performans indeksi (Tei indeksi- MPI) hasta grubunda anlamlı olarak yüksek bulundu (İkisi için p=0,05). KPET sırasında, hasta grubunun atım hacmi ve VO2max düzeyleri kontrol grubundan anlamlı olarak düşük bulunmuştur (Sırasıyla p=0,004, p=0,044). Sonuç: Opere edilmiş FT hastaları orta dönemde asemptomatik olsalar da bu hastalardaki egzersiz kapasitesi sağlıklı bireylere göre düşüktür ve bu düşüklük sağ ventrikül boyutu ve disfonksiyonu ile ilişkilidir.

Keywords

• Fallot tetralojisi
• Egzersiz Kapasitesi
• Aritmi

Project Number

09.2016.216

Ethical Statement

Bu çalışmada sunduğum verileri, bilgileri akademik ve etik kurallar içinde elde ettiğimi , tüm bilgi ,belge, değerlendirme ve sonuçları bilimsel etik ve ahlak kurallarına uygun olarak sunduğumu, bu çalışmada yararlandığım eserlerin tümüne uygun atıfta bulunarak kaynak gösterdiğimi, kullanılan verilerde herhangi bir değişiklik yapmadığımı ve çalışmanın özgün olduğunu bildiririm. Aksi bir durumda aleyhime doğabilecek tüm hak kayıplarını kabullendiğimi beyan ederim.

References

1. Lillehei CW, Cohen M, Warden HE, Read RC, Aust JB, Dewall RA, et al. Direct vision intracardiac surgical correction of the tetralogy of Fallot, pentalogy of Fallot, and pulmonary atresia defects; report of first ten cases. Ann Surg. 1955 Sep;142(3):418-42. doi:10.1097/00000658- 195509000-00010 PMID: 13249340; PMCID: PMC1465089.
2. Sarris GE, Comas JV, Tobota Z, Maruszewski B. Results of reparative surgery for tetralogy of Fallot: data from the European Association for Cardio-Thoracic Surgery Congenital Database. Eur J Cardiothorac Surg. 2012 Nov;42(5):766-74; Discussion 774. doi:10.1093/ejcts/ezs478 PMID: 23087090.
3. Akalın F. Long Term Follow up in Patients with Tetralogy of Fallot: Problems and Management. TürkiyeKlinikleri J Cardiol-Special Topics. 2008;1(5):1-8.
4. Ren C, Zhu J, Shen T, Song Y, Tao L, Xu S, et al. Comparison between treadmill and bicycle ergometer exercises in terms of safety of cardiopulmonary exercise testing in patients with coronary heart disease. Front Cardiovasc Med. 2022 Jun 20;9:864637. doi:10.3389/fcvm.2022.864637 PMID: 35795362; PMCID: PMC9251120.
5. Leonardi B, Gentili F, Perrone MA, Sollazzo F, Cocomello L, Silva Kikina, et al. Cardiopulmonary exercise testing in repaired tetralogy of Fallot: Multiparametric overview and correlation with cardiac magnetic resonance and physical activity level. J Cardiovasc Dev Dis. 2022 Jan 13;9(1):26. doi:10.3390/jcdd9010026 PMID: 35050237; PMCID: PMC8778451.
6. Teng HC, Chen YC, Chen YL, Weng KP, Pan JY, Chang MH, et al. Morphometrics predicts the differential regurgitant fraction in bilateral pulmonary arteries of patients with repaired tetralogy of Fallot. Int J Cardiovasc Imaging. 2024 Mar;40(3):655-664. doi:10.1007/s10554-023-03035-1 Epub 2024 Feb 16. PMID: 38363435; PMCID: PMC10950999.
7. Gatzoulis MA, Till JA, Somerville J, Redington AN. Mechanoelectrical interaction in tetralogy of Fallot: QRS prolongation relates to right ventricular size and predicts malignant ventricular arrhythmias and sudden death. Circulation. 1995 Jul 15;92(2):231-7. doi:10.1161/01.cir.92.2.231 PMID: 7600655.
8. Çetin I, Tokel K, Varan B, Orün UA, Gökdemir M, Cindik N, et al. Evaluation of right ventricular functions and B-type natriuretic peptide levels by cardiopulmonary exercise test in patients with pulmonary regurgitation after repair of tetralogy of Fallot. J Card Surg. 2008 Sep-Oct;23(5):493-8. doi:10.1111/j.1540-8191.2008.00634.x Erratum in: J Card Surg. 2009 May-Jun;24(3):359-61. PMID: 18928486.

9. Cardoso SM, Miyague NI. Right ventricular diastolic dysfunction in the postoperative period of tetralogy of Fallot. Arq Bras Cardiol. 2003 Feb;80(2):198-201, 194-7. doi:10.1590/s0066-782x2003000200008 Epub 2003 Feb 25. PMID: 12640513.
10. Abd El Rahman MY, Abdul-Khaliq H, Vogel M, Alexi-Meskischvili V, Gutberlet M, Hetzer R, et al. Value of the new Doppler-derived myocardial performance index for the evaluation of right and left ventricular function following repair of tetralogy of fallot. Pediatr Cardiol. 2002 Sep-Oct;23(5):502-7. doi:10.1007/s00246-002-1469-5 PMID: 12189405.
11. Adams CW. Bernheim effect (produced by an interventricular septal aneurysm following septal infarction). Dis Chest. 1966 Dec;50(6):641-2. doi:10.1378/chest.50.6.641 PMID: 5964871.
12. West JB. Cardiac energetics and myocardial oxygen consumption. In: Physiologic Basis of Medical Practice. Baltimore, MD: Williams and Wilkins; 1981:250-260.
13. Martins IF, Doles IC, Bravo-Valenzuela NJM, Santos AORD, Varella MSP. When is the best time for corrective surgery in patients with tetralogy of Fallot between 0 and 12 months of age? Braz J Cardiovasc Surg. 2018 Sep-Oct;33(5):505-510. doi:10.21470/1678-9741-2018-0019 PMID: 30517260; PMCID: PMC6257527.
14. Mongeon FP, Gurvitz MZ, Broberg CS, Aboulhosn J, Opotowsky AR, Kay JD, et al. Alliance for Adult Research in Congenital Cardiology (AARCC). Aortic root dilatation in adults with surgically repaired tetralogy of fallot: A multicenter cross- sectional study. Circulation. 2013 Jan 15;127(2):172-9. doi:10.1161/CIRCULATION AHA.112.129585 Epub 2012 Dec 6. PMID: 23224208.
15. Uebing A, Fischer G, Bethge M, Scheewe J, Schmiel F, Stieh J, et al. Influence of the pulmonary annulus diameter on pulmonary regurgitation and right ventricular pressure load after repair of tetralogy of Fallot. Heart. 2002 Nov;88(5):510-4. doi:10.1136/heart.88.5.510 PMID: 12381646; PMCID: PMC1767417.
16. Giardini A, Specchia S, Tacy TA, Coutsoumbas G, Gargiulo G, Donti A, et al. Usefulness of cardiopulmonary exercise to predict long-term prognosis in adults with repaired tetralogy of Fallot. Am J Cardiol. 2007 May 15;99(10):1462-7. doi:10.1016/j.amjcard.2006.12.076 Epub 2007 Apr 5. PMID: 17493481.
17. Carvalho JS, Shinebourne EA, Busst C, Rigby ML, Redington AN. Exercise capacity after complete repair of tetralogy of Fallot: deleterious effects of residual pulmonary regurgitation. Br Heart J. 1992 Jun;67(6):470-3. doi:10.1136/hrt.67.6.470 PMID: 1622697; PMCID: PMC1024889.
18. Shafer KM, Opotowsky AR, Rhodes J. Exercise testing and spirometry as predictors of mortality in congenital heart disease: Contrasting Fontan physiology with repaired tetralogy of Fallot. Congenit Heart Dis. 2018 Nov;13(6):903-910. doi:10.1111/chd.12661 Epub 2018 Sep 14. PMID: 30216689.
19. Diller GP, Dimopoulos K, Okonko D, Li W, Babu-Narayan SV, Broberg CS, et al. Exercise intolerance in adult congenital heart disease: comparative severity, correlates, and prognostic implications. Circulation. 2005;112(6):828-835. doi:10.1161/CIRCULATIONAHA.104.529800
20. Khairy P, Aboulhosn J, Gurvitz MZ, Opotowsky AR, Mongeon FP, Kay J,etal. Alliance for Adult Research in Congenital Cardiology (AARCC). Arrhythmia burden in adults with surgically repaired tetralogy of Fallot: A multi-institutional study. Circulation. 2010 Aug 31;122(9):868-75. doi:10.1161/CIRCULATIONAHA.109.928481 Epub 2010 Aug 16. PMID: 20713900.
21. Harrison DA, Harris L, Siu SC, MacLoghlin CJ, Connelly MS, Webb GD, et al. Sustained ventricular tachycardia in adult patients late after repair of tetralogy of Fallot. J Am Coll Cardiol. 1997 Nov 1;30(5):1368-73. doi:10.1016/s0735-1097(97)00316-1 PMID: 9350941.