Right Ventricular Strain in Repaired Tetralogy of Fallot After Pulmonary Valve Replacement With Reconstructed Radial Long-axis Cine Magnetic Resonance Images

doi:10.21203/rs.3.rs-633342/v1

Download PDF

Research Article

Right Ventricular Strain in Repaired Tetralogy of Fallot After Pulmonary Valve Replacement With Reconstructed Radial Long-axis Cine Magnetic Resonance Images

https://doi.org/10.21203/rs.3.rs-633342/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Objectives: To investigate changes in right ventricular (RV) strain after pulmonary valve replacement (PVR) in repaired tetralogy of Fallot (TOF) by applying a novel postprocessing technique to conventional short-axis cine MRI to measure RV strains before and after PVR.

Methods: Twenty-four patients with repaired TOF who underwent PVR and 16 healthy controls were enrolled. Global maximum and minimum principal strains (GPS_max, GPS_min) and global circumferential and longitudinal strains (GCS, GLS) were measured from short-axis cine images reconstructed radially along the long axis. Strain parameters before and after PVR were compared using paired t-tests. One-way ANOVA with Tukey post-hoc analysis was used for comparisons between the before and after PVR groups and the control group.

Results: There were no differences in strain parameters before and after PVR. The GPS_max before PVR was lower than that in the control group (P=0.002). Before and after PVR, GCSs were higher and GLSs were lower than those in the control group (before and after GCSs: P=0.002 for both, before and after GLSs: P<0.0001 and P=0.0003).

Conclusions: RV strains from radially reconstructed short-axis cine images revealed impaired myocardial motion after PVR. When compared to the control group, changes in GCS and GLS in TOF patients before and after PVR might be due to RV remodeling.

Nuclear Medicine & Medical Imaging

Cardiac & Cardiovascular Systems

Right ventricular strain

pulmonary valve replacement (PVR)

Fallot

radial long-axis

magnetic resonance images

Patients with surgically repaired TOF experience significant morbidity and mortality related to biventricular dysfunction and arrhythmia in their adult years [1–3]. These sequelae are believed to be in part related to chronic pulmonary regurgitation caused by efforts to relieve pulmonary valve stenosis with the initial repair. PVR is performed to improve pulmonary regurgitation or valvular stenosis and improve long-term outcomes [4, 5] in adult patients with repaired TOF. However, cardiovascular magnetic resonance (CMR) feature tracking showed that ventricular strain was unchanged, even after PVR [6].

Peak strain is a helpful marker for quantifying myocardial tissue deformation [7–9], especially in the RV, because the image quality of echocardiography is sometimes inadequate [10, 11]. Generally, the RV strain is evaluated using circumferential strain (CS) or longitudinal strain (LS) from the motion of the endocardium in one plane of the ventricular short- or long-axis, respectively. However, the motion of the heart is three-dimensional. Accordingly, such predefined directions of change may not reliably describe deformation in the dominant direction of tissue movement established by engaged myocardial fibers. On the other hand, three-dimensional image acquisition for myocardial strain is technically difficult and time-consuming, if possible. Recently, the feasibility of three-dimensional image analysis using routine cine CMR images for the estimation of principal strain (PS), a geometry-independent measure established from the dominant direction of local tissue deformation, has been reported [12]. Therefore, the aim of this study was to investigate the change in three-dimensional “real” strain after PVR in repaired TOF by applying this novel post-processing technique to conventional two-dimensional cine imaging. In the present study, we measured changes in RV PS before and after PVR. We also investigated the clinical impact of the relationship between strain parameters and clinical and hemodynamic measurements.

Table 1 shows the baseline characteristics, CMR RV parameters, and cardiac catheterization parameters. After PVR, the World Health Organization class and RV volume parameters showed significant improvement.

Table 1

Baseline clinical characteristics, CMR right ventricular parameters, and right heart catheterization parameters
	TOF patients (n = 24)		P-value	Control (n = 16)
	Before PVR	After PVR	P-value	Control (n = 16)
Age before PVR (y)	26 ± 9			33 ± 11
Male/Female	11/13			13/3
Body surface area before PVR (m²)	1.58 ± 0.17			1.76 ± 0.13
WHO classification (Ⅰ/Ⅱ/Ⅲ/Ⅳ)	17/5/2/0	23/1/0/0		16/0/0/0
CMR to PVR duration (day)	252 ± 158
PVR to CMR duration (day)		433 ± 163
CMR RV parameters
HR (bpm)	70 ± 12	69 ± 9	0.41	66 ± 14
RVEDVi (mL/m²)	165.7 ± 41.9	108.7 ± 19.0	< 0.0001	71.0 ± 18.0
RVESVi (mL/m²)	94.2 ± 29.7	66.0 ± 14.7	< 0.0001	28.8 ± 10.9
RVEF (%)	43.8 ± 7.8	39.3 ± 7.1	0.02	60.5 ± 6.3
RVSVi (mL/m²)	71.4 ± 19.5	42.7 ± 10.3	< 0.0001	42.2 ± 8.1
Cardiac catheterization
RVP (mmHg)	51.9 ± 18.8
LVP (mmHg)	122.3 ± 17.0
PA pressure (mmHg)	34.5 ± 12.0
RVP/ LVP	0.43 ± 0.18
RV-PA pressure gradient	17.4 ± 17.3
CMR, cardiovascular magnetic resonance; EDVi, indexed end-diastolic volume; EF, ejection fraction; ESVi, indexed end-systolic volume; HR, heart rate; LVP, left ventricular pressure; PA, pulmonary artery; PVR, pulmonary valve replacement; RV, right ventricular; RVP, right ventricular pressure; SVi, stroke volume index; TOF, tetralogy of Fallot; WHO, World Health Organization

Figure 1 shows the global strain parameters in the patients before and after PVR and in the control group. There were no differences in any of the strain parameters before and after PVR. The GPS_max before PVR was lower than that in the control group (P = 0.002). GCSs before and after PVR were higher than those in the control groups (P = 0.002 for both). GLSs before and after PVR were lower than those in the controls (P < 0.0001 and P = 0.0003). The r_S (confidence intervals) indicated significant correlations between the GPS_min and RVP/ LVP (r_S = − 0.44 [–0.72, − 0.03]) and between the GPS_min and the RV-PA pressure gradient (r_S = − 0.54 [–0.78, − 0.16]) (Fig. 2). In addition, the GPS_max was significantly correlated with RVP/ LVP and with the RV-PA pressure gradient (r_S = 0.47 [0.08, 0.74], r_S = 0.64 [0.31, 0.83]) (Fig. 2).

There were strong correlations between intra- and inter-observer strains (P < 0.01). Excellent intra-observer and inter-observer reproducibility were observed for RV strain measurements using radial long-axis reconstructed cine images (Table 2).

Table 2

Reproducibility of strain measurements
	Intra-observer reproducibility				Inter-observer reproducibility
Strain parameters	r (95% CI)	Bias (LOA)	SDD	ICC (95% CI)	r (confidence intervals)	Bias (LOA)	SDD	ICC (95% CI)
GPS_min	0.95 (0.81, 0.99)	–0.7 % (–3.9, 2.5)	1.6	0.94 (0.78–0.98)	0.84 (0.45, 0.96)	–0.1 % (–5.5, 5.4)	2.8	0.83 (0.46–0.96)
GPS_max	0.94 (0.75, 0.99)	0.4 % (–2.1, 3.5)	1.4	0.92 (0.74–0.98)	0.85 (0.49, 0.96)	0.1 % (–3.9, 4.0)	2.0	0.85 (0.52–0.96)
GCS	0.80 (0.35, 0.95)	–0.4 % (–9.8, 8.9)	4.8	0.82 (0.45–0.95)	0.86 (0.49, 0.97)	0.9 % (–7.5, 9.4)	4.3	0.86 (0.52–0.96)
GLS	0.89 (0.59, 0.97)	–1.2 % (–6.2, 3.8)	2.6	0.88 (0.60–0.97)	0.86 (0.50, 0.97)	–1.1 % (–7.0, 4.9)	3.0	0.86 (0.54–0.96)
r, Pearson’s correlation coefficients; GPS_min, global minimum principal strain; GPS_max, global maximum principal strain; GCS, global circumferential strain; GLS, global longitudinal strain; LOA, limit of agreement; SDD, standard deviation of the difference; ICC, intraclass correlation coefficient; CI, confidence interval.

According to our investigation, there were no differences in global PS values before and after PVR in adult patients with surgically repaired TOF. Furthermore, GCS and GLS were unchanged before and after PVR. Our results are in line with those of previous research [6]. Therefore, PVR in patients with repaired TOF led to no changes in RV global PS. There were no differences in global PS between the patients after PVR and the control group, although the RV volume parameters were not normalized. This may indicate that RV myocardial motility is maintained by remodeling, corresponding to long-term pressure overloading. The mean RV ESVi in the patients before PVR was 94 mL/m², which corresponds to the previously reported adaptive RV remodeling conditions (73 to 113 mL/m²) [13]. Furthermore, in RV pressure overload, it is mainly the middle myocardial layer that hypertrophies [14, 15]. The RV in patients with adapted remodeling is similar to the normal left ventricle, which has a well-developed middle circumferential layer [16]. Thus, the increase in the circumferential fiber mass may also contribute to the predominant circumferential RV free-wall shortening. According to our results, increased GCS and decreased GLS in the TOF group relative to the control group were consistent with these reports. Furthermore, our results suggest that even if the RV volume is reduced by PVR, there is no reverse remodeling of myocardial motion 1 year after the surgery. Earlier surgical intervention might be preferable to prevent myocardial remodeling.

In clinical situations, pressure parameters derived from cardiac catheterization are important indicators for PVR. We found that CMR-derived GPS_min and GPS_max were significantly correlated. The advantage of CMR with respect to cardiac catheterization is its accurate volume measurement and low invasiveness. However, its weakness is an inability to measure the pressure in the cardiac cavity or blood vessels. Surgical indications for PVR include volumetric parameters (e.g., RV dilatation) and pressure parameters (e.g., RVP/LVP). The estimation of pressure-derived parameters using our method has the potential to overcome CMR’s weakness. Because our strain analysis requires only short-axis cine CMR, a well-established method without the need for additional imaging, a wider range of applications could be expected.

We acknowledge that our strain analysis with radially reconstructed long-axis cine CMR was based on the original in-house algorithm. Although measurements of RV PS with echocardiography using commercial software have been reported [17, 18], no software has been established for RV PS for CMR. We considered that the values of PS, GCS, and GLS were clinically reasonable and reliable in the study populations. Furthermore, the reproducibility of the strain measurements with radially reconstructed long-axis images was compared with CMR-derived strain measurements using feature tracking [19, 20]. For future research, it will be necessary to verify the technique by applying the analysis to different right heart diseases and investigating their relationship with other clinical indicators and prognoses.

In this cohort, the three-dimensional PS revealed impaired RV myocardial motion after PVR. In TOF patients before and after PVR, changes in GCS and GLS with respect to the control group might be due to RV remodeling. PS values reconstructed by short-axis CMR images were correlated with the parameters of pressure overloading with cardiac catheterization.

Patients

This retrospective observational study was approved by the institutional review board of Kyushu University and conducted in accordance with the 1964 Declaration of Helsinki. Written informed consent was obtained from each patient. Twenty-four patients with surgically repaired TOF who underwent PVR were enrolled in the study, and datasets derived between October 2012 and March 2018 were analyzed. All patients were older than 18 years and underwent CMR assessment and cardiac catheterization of the right and left heart before PVR. In addition, CMR control data were obtained from 16 age- and sex-matched healthy subjects.

Cardiac catheterization

All patients with repaired TOF underwent left and right heart catheterization before PVR. Cardiac catheterization provided pressure parameters of the left ventricular, right ventricular, and pulmonary arteries.

Cine CMR imaging

Cine CMR was performed following a previous research [21] using a 3.0T clinical scanner (Ingenia 3.0T CX; Philips Healthcare) with a dStream Torso coil using electrocardiographic gating. Steady-state free precession images were obtained using multi-breath holding with retrospective electrocardiogram gating in the axial and short-axis views covering the entire right ventricle with 20 phases per cardiac cycle. The axial cine imaging parameters were as follows: repetition time = 2.4 ms, echo time = 1.18 ms, SENSE factor = 2.0, flip angle = 35°, slice thickness = 8 mm, slice gap = 0 mm, field of view = 380 × 380 mm, acquisition matrix 176 × 245, and reconstruction matrix 448 × 448. The short-axis cine imaging parameters were as follows: repetition time = 2.7 ms, echo time = 1.37 ms, SENSE factor = 2.0, flip angle = 45°, slice thickness = 8 mm, slice gap = 0 mm, field of view = 380 × 435 mm, acquisition matrix 176 × 142, and reconstruction matrix 512 × 512. RV volume analysis was performed semi-automatically with subsequent manual correction using a workstation (IntelliSpace Portal, Philips Healthcare). RV volumes were measured using axial images, as previously reported [22]. End-diastolic volume (EDV) and end-systolic volume (ESV) were indexed to the body surface area. The ejection fraction (EF) was calculated using EDV and ESV. Stroke volume index (SVi) was calculated as the difference between indexed EDV and ESV values (EDVi and ESVi, respectively). The cardiac index was the product of the SVi and the heart rate (HR).

Strain analysis with CMR

All image processing algorithms for CMR-derived strain analyses were implemented using MATLAB R2020a (MATLAB Runtime Version 9.8; The MathWorks Inc.). Strain values were calculated from the three-dimensional coordinates of the RV endocardial point using standard short-axis cine CMR images. First, the point of the RV center was manually determined on the mid-heart short-axis slice during systole (Fig. 3a). The images interpolated to the slice direction using the nearest-neighbor method were then automatically reconstructed into six radial long-axis images at 30° around the RV point (Fig. 3b). Radial long-axis reconstructions were performed at the end-diastolic and end-systolic frames. Second, the RV areas were manually segmented on 12 images of six long-axis images with radial projection at the end-diastolic and end-systolic frames (Fig. 3c). Then, the RV endocardial lines were automatically replaced with evenly distributed points (Fig. 3d). Eighteen points were included in this study. Finally, the three-dimensional coordinates of 108 points of RV per frame (18 points for every 6 projections) were automatically obtained at the end-diastolic and end-systolic frames. The RV endocardial surface was individually modeled with these points for patient (Fig. 3e). Regional strains (ε), the percentages at each point, were calculated from the orthogonal lengths of circumferential, longitudinal, and radial directions at end-systole with respect to the lengths at end-diastole (Fig. 4) using Eq. (1):

(1)

Further, the maximum and minimum PS were calculated from the three orthogonal regional strains, as per the previous research [12]. In the present study, the GPS_max and GPS_min were determined as the mean values of maximum and minimum PS of all RV endocardial points, respectively. The GCS and GLS were the means of the strains in the circumferential and longitudinal directions for all RV endocardial points, respectively.

Statistical analysis

All statistical analyses were performed using GraphPad Prism version 8.1.2. (GraphPad Software, Inc.). Differences were considered statistically significant at P < 0.05. The Shapiro–Wilk test was used to evaluate the normality of the data distribution, and the mean and standard deviations were calculated. All strain parameters before and after PVR were compared using paired t-tests. One-way ANOVA with Tukey post-hoc analysis, was used for the comparisons between patient groups before and after PVR and the control group. Spearman correlation coefficients (r_S) between the GPS_min and the right ventricular to left ventricular pressure (RVP/ LVP) ratio and between the GPS_min and RV to pulmonary artery (PA) pressure gradient were calculated. Similarly, the r_S for GPS_max were also calculated.

Intra-observer and inter-observer reproducibility

The intra-observer reproducibility of the image analysis for strain calculations was evaluated following a previous research [23]. A single observer performed all analyses for 10 randomly selected patients and then blindly repeated the analyses at least 1 month later. Inter-observer reproducibility was evaluated based on the same 10 patients and performed by a second observer who was blinded to the clinical and experimental data. Pearson’s correlation coefficients of intra- and inter-observer strain parameters were calculated. The intra-observer and inter-observer reproducibility of the strain measurements was evaluated using Bland–Altman analyses and intraclass correlation coefficients (ICC) with one-way or two-way random single measures (ICC [1, 1] or ICC [2, 1], respectively). The ICC values were defined as excellent (≥ 0.75), good (0.60–0.74), moderate (0.40–0.59), or poor (≤ 0.39).

Data availability

Reprints and permissions information is available.

Acknowledgements

This work was supported by the Center for Clinical and Translational Research of Kyushu University Hospital. This work was supported by JSPS KAKENHI JP20K16729. We thank Editage (www.editage.com) for the English language editing.

Author contributions

Guarantors of integrity of entire study, M.K., Y.Y.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; agrees to ensure any questions related to the work are appropriately resolved, all authors; literature research, M.K., Y.Y., D.T; clinical studies, Y.Y., D.T., K.Y., I.S.; statistical analysis, M.K., T.M.; and manuscript editing, M.K., Y.Y., H.Y., K.I.

Competing interests

The authors declare no competing interests.

Cuypers J. A. et al. Unnatural history of tetralogy of Fallot: prospective follow-up of 40 years after surgical correction. Circulation 130, 1944–1953 (2014).
Geva T., Sandweiss B. M., Gauvreau K., Lock J. E. & Powell A. J. Factors associated with impaired clinical status in long-term survivors of tetralogy of Fallot repair evaluated by magnetic resonance imaging. J. Am. Coll. Cardiol. 43, 1068–1074 (2004).
Valente A. M. et al. Contemporary predictors of death and sustained ventricular tachycardia in patients with repaired tetralogy of Fallot enrolled in the INDICATOR cohort. Heart 100, 247–253 (2014).
Cheung E. W., Wong W. H. & Cheung Y. F. Meta-analysis of pulmonary valve replacement after operative repair of tetralogy of Fallot. Am. J. Cardiol. 106, 552–557 (2010).
Ferraz Cavalcanti P. E. et al. Pulmonary valve replacement after operative repair of tetralogy of Fallot: meta-analysis and meta-regression of 3,118 patients from 48 studies. J. Am. Coll. Cardiol. 62, 2227–2243 (2013).
Balasubramanian S. et al. Impact of surgical pulmonary valve replacement on ventricular strain and synchrony in patients with repaired tetralogy of Fallot: a cardiovascular magnetic resonance feature tracking study. J. Cardiovasc. Magn. Reson. 20, 37; 10.1186/s12968-018-0460-0 (2018).
Bakos Z. et al. A comparison between radial strain evaluation by speckle-tracking echocardiography and cardiac magnetic resonance imaging, for assessment of suitable segments for left ventricular lead placement in cardiac resynchronization therapy. Europace 16, 1779–1786 (2014).
Reindl M. et al. Prognostic implications of global longitudinal strain by feature-tracking cardiac magnetic resonance in ST-elevation myocardial infarction. Circ. Cardiovasc. Imaging 12, e009404; 10.1161/CIRCIMAGING.119.009404 (2019).
Mordi I., Bezerra H., Carrick D. & Tzemos N. The combined incremental prognostic value of LVEF, late gadolinium enhancement, and global circumferential strain assessed by CMR. JACC Cardiovasc. Imaging 8, 540–549 (2015).
Haddad F., Hunt S. A., Rosenthal D. N. & Murphy D. J. Right ventricular function in cardiovascular disease, part I: Anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation 117, 1436–1448 (2008).
Ostenfeld E. & Flachskampf F. A. Assessment of right ventricular volumes and ejection fraction by echocardiography: from geometric approximations to realistic shapes. Echo. Res. Pract. 2, R1–R11 (2015).
Satriano A. et al. Clinical feasibility and validation of 3D principal strain analysis from cine MRI: comparison to 2D strain by MRI and 3D speckle tracking echocardiography. Int. J. Cardiovasc. Imaging 33,1979–1992 (2017).
Ryo K. et al. Characterization of right ventricular remodeling in pulmonary hypertension associated with patient outcomes by 3-dimensional wall motion tracking echocardiography. Circ. Cardiovasc. Imaging 8, e003176; 10.1161/CIRCIMAGING.114.003176 (2015).
Sanchez-Quintana D., Anderson R. H. & Ho S. Y. Ventricular myoarchitecture in tetralogy of Fallot. Heart 76, 280–286 (1996).
Tezuka F., Hort W., Lange P. E. & Nürnberg J. H. Muscle fiber orientation in the development and regression of right ventricular hypertrophy in pigs. Acta. Pathol. Jpn. 40, 402–407 (1990).
Greenbaum R. A., Ho S. Y., Gibson D.G., Becker A. E. & Anderson R. H. Left ventricular fibre architecture in man. Br. Heart J. 45, 248–263 (1981).
Satriano A. et al. Characterization of right ventricular deformation in pulmonary arterial hypertension using three-dimensional principal strain analysis. J. Am. Soc. Echocardiogr. 32, 385–393 (2019).
Sato T., Calderon R. J., Klas B., Pedrizzetti G. & Banerjee A. Simultaneous volumetric and functional assessment of the right ventricle in hypoplastic left heart syndrome after Fontan palliation, utilizing 3-dimensional speckle-tracking echocardiography. Circ. J. 84, 235–244 (2020).
Kawakubo M. et al. Clinical usefulness of right ventricular 3D area strain in the assessment of treatment effects of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension: comparison with 2D feature-tracking MRI. Eur. Radiol. 29, 4583–4592 (2019).
Schmidt B. et al. Intra- and inter-observer reproducibility of global and regional magnetic resonance feature tracking derived strain parameters of the left and right ventricle. Eur. J. Radiol. 89, 97–105 (2017).
Yamasaki Y. et al. Balloon pulmonary angioplasty improves right atrial reservoir and conduit functions in chronic thromboembolic pulmonary hypertension. Eur. Heart. J. Cardiovasc. Imaging 21, 855–862 (2020).
Alfakih K. et al. Comparison of right ventricular volume measurements between axial and short axis orientation using steady-state free precession magnetic resonance imaging. J. Magn. Reson. Imaging 18, 25-32 (2003).
Kawakubo M. et al. Feature-Tracking MRI Fractal Analysis of Right Ventricular Remodeling in Adults with Congenitally Corrected Transposition of the Great Arteries. Radiol. Cardiothorac. Imaging 1, e190026; 10.1148/ryct.2019190026 (2019).

No competing interests reported.

Download PDF

Editorial decision: Major revision
10 Aug, 2021
Reviews received at journal
04 Jul, 2021
Reviewers agreed at journal
02 Jul, 2021
Reviewers invited by journal
01 Jul, 2021
Editor assigned by journal
01 Jul, 2021
Editor invited by journal
21 Jun, 2021
Submission checks completed at journal
21 Jun, 2021
First submitted to journal
17 Jun, 2021

You are reading this latest preprint version

Right Ventricular Strain in Repaired Tetralogy of Fallot After Pulmonary Valve Replacement With Reconstructed Radial Long-axis Cine Magnetic Resonance Images

Status:

Version 1

Abstract

Figures

Introduction

Results

Discussion

Methods

Patients

Cardiac catheterization

Cine CMR imaging

Strain analysis with CMR

Statistical analysis

Intra-observer and inter-observer reproducibility

Declarations

References

Additional Declarations

Status:

Version 1