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Title: Ventricular flow analysis and its association with exertional capacity in repaired tetralogy of Fallot: 4D flow cardiovascular magnetic resonance study
Authors: Zhao, Xiaodan 
Hu, Liwei
Leng, Shuang 
Tan, Ru-San 
Chai, Ping 
Bryant, Jennifer Ann 
Teo, Lynette LS 
Fortier, Marielle V 
Yeo, Tee Joo 
Ouyang, Rong Zhen
Allen, John C 
Hughes, Marina
Garg, Pankaj
Zhang, Shuo
van der Geest, Rob J
Yip, James W
Tan, Teng Hong 
Tan, Ju Le
Zhong, Yumin
Zhong, Liang 
Keywords: Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Radiology, Nuclear Medicine & Medical Imaging
Cardiovascular System & Cardiology
Repaired tetralogy of Fallot
Kinetic energy
4D flow CMR
Flow components
Cardiopulmonary exercise testing
Issue Date: 3-Jan-2022
Publisher: BMC
Citation: Zhao, Xiaodan, Hu, Liwei, Leng, Shuang, Tan, Ru-San, Chai, Ping, Bryant, Jennifer Ann, Teo, Lynette LS, Fortier, Marielle V, Yeo, Tee Joo, Ouyang, Rong Zhen, Allen, John C, Hughes, Marina, Garg, Pankaj, Zhang, Shuo, van der Geest, Rob J, Yip, James W, Tan, Teng Hong, Tan, Ju Le, Zhong, Yumin, Zhong, Liang (2022-01-03). Ventricular flow analysis and its association with exertional capacity in repaired tetralogy of Fallot: 4D flow cardiovascular magnetic resonance study. JOURNAL OF CARDIOVASCULAR MAGNETIC RESONANCE 24 (1). ScholarBank@NUS Repository.
Abstract: Background: Four-dimensional (4D) flow cardiovascular magnetic resonance (CMR) allows quantification of biventricular blood flow by flow components and kinetic energy (KE) analyses. However, it remains unclear whether 4D flow parameters can predict cardiopulmonary exercise testing (CPET) as a clinical outcome in repaired tetralogy of Fallot (rTOF). Current study aimed to (1) compare 4D flow CMR parameters in rTOF with age- and gender-matched healthy controls, (2) investigate associations of 4D flow parameters with functional and volumetric right ventricular (RV) remodelling markers, and CPET outcome. Methods: Sixty-three rTOF patients (14 paediatric, 49 adult; 30 ± 15 years; 29 M) and 63 age- and gender-matched healthy controls (14 paediatric, 49 adult; 31 ± 15 years) were prospectively recruited at four centers. All underwent cine and 4D flow CMR, and all adults performed standardized CPET same day or within one week of CMR. RV remodelling index was calculated as the ratio of RV to left ventricular (LV) end-diastolic volumes. Four flow components were analyzed: direct flow, retained inflow, delayed ejection flow and residual volume. Additionally, three phasic KE parameters normalized to end-diastolic volume (KEiEDV), were analyzed for both LV and RV: peak systolic, average systolic and peak E-wave. Results: In comparisons of rTOF vs. healthy controls, median LV retained inflow (18% vs. 16%, P = 0.005) and median peak E-wave KEiEDV (34.9 µJ/ml vs. 29.2 µJ/ml, P = 0.006) were higher in rTOF; median RV direct flow was lower in rTOF (25% vs. 35%, P < 0.001); median RV delayed ejection flow (21% vs. 17%, P < 0.001) and residual volume (39% vs. 31%, P < 0.001) were both greater in rTOF. RV KEiEDV parameters were all higher in rTOF than healthy controls (all P < 0.001). On multivariate analysis, RV direct flow was an independent predictor of RV function and CPET outcome. RV direct flow and RV peak E-wave KEiEDV were independent predictors of RV remodelling index. Conclusions: In this multi-scanner multicenter 4D flow CMR study, reduced RV direct flow was independently associated with RV dysfunction, remodelling and, to a lesser extent, exercise intolerance in rTOF patients. This supports its utility as an imaging parameter for monitoring disease progression and therapeutic response in rTOF. Clinical Trial Registration Unique identifier: NCT03217240.
ISSN: 10976647
DOI: 10.1186/s12968-021-00832-2
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