natriuretic-peptide--brain and Tetralogy-of-Fallot

The benefits of pulmonary valve replacement (PVR) for pulmonary insufficiency in patients with repaired tetralogy of Fallot are still incompletely understood, and optimal timing remains challenging.. We systematically reviewed databases (PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials /Cochrane Controlled Trials Register, ClinicalTrials.gov, Scientific Electronic Library Online, Literatura Latino Americana em Ciências da Saúde, and Google Scholar) and reference lists of relevant articles for studies about PVR in repaired tetralogy of Fallot patients that reported any of the following outcomes: mortality and redo PVR rates, right ventricular (RV) and left ventricular measures, QRS duration, cardiopulmonary exercise test results, or brain natriuretic peptide. In addition to calculating the pooled treatment effects using a random-effects meta-analysis, we evaluated the effect of preoperative measures on PVR outcomes using meta-regressions.. Eighty-four studies involving 7544 patients met the eligibility criteria. Pooled mortality at 30 days, 5 years, and 10 years after PVR was 0.87% (63 of 7253 patients, 80 studies), 2.7% (132 of 4952 patients, 37 studies), and 6.2% (510 of 2765 patients, 15 studies), respectively. Pooled 5- and 10-year redo PVR rates were 3.7% (141 of 3755 patients, 23 studies) and 16.8% (172 of 3035 patients, 16 studies), respectively. The results of the previous meta-analysis could be confirmed. In addition, we demonstrated that after PVR (1) QRS duration, cardiopulmonary exercise test results, and RV and left ventricular measures longitudinal strain do not significantly change; (2) brain natriuretic peptide decreases; and (3) greater indexed RV end-diastolic and end-systolic volumes are associated with lower chances of RV volume normalization after PVR.. This updated meta-analysis provides evidence about the benefits of PVR.

Topics: Heart Valve Prosthesis Implantation; Humans; Natriuretic Peptide, Brain; Pulmonary Valve; Pulmonary Valve Insufficiency; Retrospective Studies; Tetralogy of Fallot; Treatment Outcome

The metabolic disorders associated with chronic hypoxemia in adult patients with tetralogy of Fallot (TOF) have not been fully appreciated. We report a 53-year-old male patient with TOF who presented with fasting hypoglycemia, hypertriglyceridemia, increased blood levels of free fatty acids, adiponectin, B-type natriuretic peptide, and uric acid. The cluster of these metabolic derangements has not been previously reported, and the possible role of chronic hypoxia in the production of these disturbances is discussed with a review of pertinent literatures.

Topics: Adiponectin; Fatty Acids, Nonesterified; Glucose Intolerance; Humans; Hypertriglyceridemia; Hypoglycemia; Hypoxia; Male; Middle Aged; Natriuretic Peptide, Brain; Tetralogy of Fallot

 Most patients with surgically corrected tetralogy of Fallot (TOF) are faced with multiple residua and sequelae such as pulmonary regurgitation (PR), resulting in reoperation for pulmonary valve replacement (PVR). Plasma brain natriuretic peptide (BNP) level and serum N-terminal pro-BNP (NT-pro-BNP) level are useful as diagnostic objective markers of chronic heart failure (CHF). The aim of the study was to examine whether these markers have predictive ability for reoperation in children with surgically corrected TOF..  Fifty-eight patients (38 male, 20 female) aged 1-18 years (median, 7 years) were enrolled. Serum NT-pro-BNP in TOF patients was significantly higher than in age-matched hospital controls without CHF (359.5±449.7pg/ml vs. 86.1±45.1pg/ml, respectively; P<0.0001). BNP and NT-pro-BNP had a better correlation with CHF index, RVEDP, and LVEDV in TOF groups. Children with surgically corrected TOF who had indication for PVR had higher BNP and NT-pro-BNP and more severe PR than those without indication for PVR. On multivariate logistic regression analysis, NT-pro-BNP was the strongest predictor for reoperation in patients with surgically corrected TOF. Area under the curve of NT-pro-BNP for reoperation was 0.950 (P<0.001) with a sensitivity of 88.9% and specificity of 91.8%..  NT-pro-BNP is a good biomarker for monitoring CHF, and is a good predictor of PVR in children with surgically repaired TOF. 

Topics: Adolescent; Biomarkers; Child; Child, Preschool; Female; Humans; Infant; Male; Natriuretic Peptide, Brain; Peptide Fragments; Predictive Value of Tests; Reoperation; Tetralogy of Fallot

Amino-terminal B-type natriuretic peptide (NT-proBNP) may detect early cardiac dysfunction in adults with tetralogy of Fallot (ToF) late after corrective surgery. We aimed to determine the value of NT-proBNP in adults with ToF and establish its relationship with echocardiography and exercise capacity.. NT-proBNP measurement, electrocardiography and detailed 2D-echocardiography were performed on the same day in 177 consecutive adults with ToF (mean age 34.6 ± 11.8 years, 58% male, 89% NYHA I, 29.3 ± 8.5 years after surgical correction). Thirty-eight percent of the patients also underwent a cardiopulmonary-exercise test. Median NT-proBNP was 16 [IQR 6.7-33.6] pmol/L, and was elevated in 55%. NT-proBNP correlated with right ventricular (RV) dilatation (r = 0.271, p < 0.001) and RV systolic dysfunction (r = -0.195, p = 0.022), but more strongly with LV systolic dysfunction (r=-0.367, p<0.001), which was present in 69 patients (39%). Moderate or severe pulmonary regurgitation was not associated with higher NT-proBNP. Tricuspid and pulmonary regurgitation peak velocities correlated with NT-proBNP (r = 0.305, p < 0.001 and r = 0.186, p = 0.045, respectively). LV twist was measured with speckle-tracking echocardiography in 71 patients. An abnormal LV twist (20 patients, 28%) was associated with elevated NT-proBNP (p = 0.030). No relationship between NT-proBNP and exercise capacity was found.. NT-proBNP levels are elevated in more than 50% of adults with corrected ToF, while they are in stable clinical condition. Higher NT-proBNP is most strongly associated with elevated pulmonary pressures, and with LV dysfunction rather than RV dysfunction. NT-proBNP has the potential to become routine examination in patients with ToF to monitor ventricular function and may be used for timely detection of clinical deterioration.

Topics: Adult; Cross-Sectional Studies; Echocardiography; Electrocardiography; Exercise Test; Female; Heart Function Tests; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Tetralogy of Fallot; Young Adult

Cardiac surgery requiring cardiopulmonary bypass and cardioplegic arrest leads to myocardial ischemic and reperfusion injury. Gaseous nitric oxide has been demonstrated to have a myocardial protective effect following ischemia-reperfusion. We hypothesized that gaseous nitric oxide administered during cardiopulmonary bypass would have similar beneficial effects.. In a prospective, randomized, blinded, placebo-controlled study, children undergoing repair of tetralogy of Fallot received either 20 ppm of gaseous nitric oxide or placebo delivered to the membrane oxygenator during cardiopulmonary bypass.. A total of 16 children were randomized into 2 equal groups once their parents or guardians had given written informed consent. No differences were found in age, crossclamp time, cardiopulmonary bypass time, or methemoglobin between the 2 groups. The group receiving gaseous nitric oxide had a significantly shortened duration of mechanical ventilation (8.4 ± 7.6 vs 16.3 ± 6.5 hours; P < .05) and intensive care unit length of stay (53.8 ± 19.7 vs 79.4 ± 37.7 hours; P < .05) compared with the placebo group. The patients had significantly lower troponin levels at 12, 24, and 48 hours (P < .05) and lower B-type natriuretic peptide levels at 12 and 24 hours (P < .05). A trend was found toward a less positive fluid balance, with significantly less diuretic usage. The study patients had a greater mean hemoglobin at 48 hours, despite the absence of differences in chest tube output, packed red blood cell transfusion, platelet counts or transfusion requirements, fresh frozen plasma transfusion, or prothrombin time/partial thromboplastin time in the first 48 hours.. The delivery of gaseous nitric oxide to the cardiopulmonary bypass circuit for children undergoing cardiac surgery results in myocardial protection, improved fluid balance, and an improved postoperative intensive care unit course.

Topics: Biomarkers; Cardiopulmonary Bypass; Female; Gases; Humans; Infant; Infant, Newborn; Intensive Care Units; Length of Stay; Male; Missouri; Myocardial Reperfusion Injury; Natriuretic Peptide, Brain; Nitric Oxide; Pilot Projects; Prospective Studies; Respiration, Artificial; Tetralogy of Fallot; Time Factors; Treatment Outcome; Troponin

Although surgical treatment for tetralogy of Fallot (TOF) has been used with considerable success, right ventricular function may remain altered after repair. The NT-proBNP assessment has been shown to be a reliable parameter for the heart failure assessment.. To determine NT-proBNP values in assessment of right ventricular function in children after TOF correction.. In 20 patients after TOF correction aged from 10 to 17 years (follow-up period ranged from 7 to 16 years) NT-proBNP level at rest and after exertion, treadmill test and echocardiography were performed. In the control healthy children NT-proBNP level at rest was assessed.. The mean values of NT-proBNP level in the TOF patients were significantly higher than in controls (11.0 +/- 12.0 fmol/l and 5.4 +/- 7.5 fmol/l, p < 0.05). In patients repaired with a transannular patch the mean value of NT-proBNP level was higher than in children operated on without a transannular patch (18.3 +/- 16.5 vs. 6.8 +/- 7.9 fmol/l, p < 0.05). In children in whom physiological shortening of QRS complex during treadmill test was observed, NT-proBNP level was lower (mean values at rest 5.0 +/- 4.8 fmol/l and after exertion 7.3 +/- 6.3 fmol/l) compared to patients with prolongation of QRS duration (mean values at rest 17.7 +/- 15.6 fmol/l and after exertion 20.3 +/- 17.8 fmol/l) (p < 0.05). Significant differences in NT-proBNP levels between children with severe pulmonary regurgitation and mild/moderate pulmonary regurgitation were detected (mean values at rest 18.6 +/- 15.0 vs. 4.2 +/- 3.9 fmol/l and after exertion 20.0 +/- 18.6 vs. 5.7 +/- 4.6 fmol/l) (p < 0.05). The NT-proBNP levels were also higher in children with severe tricuspid valve insufficiency compared to children with mild/moderate tricuspid valve regurgitation (mean values at rest 19.5 +/- 15.0 vs. 4.9 +/- 3.7 fmol/l and after exertion 22.5 +/- 17.1 vs. 7.0 +/- 4.6 fmol/l).. The NT-proBNP level in patients after TOF correction is higher than in healthy children. The NT-proBNP level is higher and exertion tolerance is lower in children repaired with rather than without transannular patch. In patients with severe pulmonary regurgitation and/or severe tricuspid valve insufficiency NT-proBNP level is higher than in patients without right ventricular volume overload. The measurement of NT-proBNP level might be helpful in order to separate those patients after TOF correction who are at increased risk of heart failure and arrhythmia.

Topics: Adolescent; Biomarkers; Cardiac Surgical Procedures; Child; Echocardiography; Exercise Test; Female; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Valve Insufficiency; Pulmonary Valve Stenosis; Tetralogy of Fallot; Tricuspid Valve Insufficiency; Ventricular Dysfunction, Right

The aim of this study was to assess the relation between plasma B-type natriuretic peptide (BNP) levels and right ventricular function evaluated by tissue Doppler imaging (TDI) in patients after repair of tetralogy of Fallot (ToF).. Twenty-five patients with a mean age of 14.1 +/- 4.4 years who underwent repair of ToF at a mean age of 4.9 +/- 5.1 years enrolled in this study. The control group consisted of 29 healthy children at a mean age of 13.1 +/- 2.8 years. The right ventricle and pulmonary regurgitation (PR) were assessed by two-dimensional echocardiography and color Doppler. Blood samples for BNP levels were taken and TDI was performed at rest.. Plasma BNP levels were significantly higher in patients than in controls (28.3 +/- 24.1 vs. 7.4 +/- 2.3 pg/mL, P = 0.0001). The myocardial performance index (MPI) (1.08 +/- 0.35 vs. 0.58 +/- 0.11, P = 0.0001) was higher and isovolumic acceleration (IVA) (3.1 +/- 0.7 vs. 5.4 +/- 1.0 m/s(2), P = 0.0001) was lower in patients. The correlations were also significant between the degree of PR and MPI (r = 0.7, P = 0.0001) and also IVA (r =-0.7, P = 0.0001). The correlations were also significant between the BNP level and MPI (r = 0.6, P = 0.0001), IVA (r =-0.4, P = 0.002) and the degree of PR (r = 0.6, P = 0.0001).. As a result, plasma BNP level increases in patients with ToF and both MPI and IVA from the right ventricular basal segments might be used to assess the right ventricular function.

Topics: Adolescent; Child, Preschool; Echocardiography, Doppler; Elasticity Imaging Techniques; Female; Humans; Male; Natriuretic Peptide, Brain; Tetralogy of Fallot; Treatment Outcome; Ventricular Dysfunction, Right

Right heart failure is a major problem of young adults with congenital heart disease (ACHD) that has been corrected by cardiac surgery. In left ventricular dysfunction (LVD), beta-blocker therapy improved cytokine concentrations and clinical status. Thus, the effect of bisoprolol on clinical status and plasma cytokine concentrations in ACHD patients with right heart failure after surgical correction for Tetralogy of Fallot was investigated.. A prospective, randomized, double-blind, placebo controlled study for a duration of 6 months was carried out. A total of 34 patients (30.9+/-9.5 years; New York Heart Association I or II) with brain natriuretic peptide plasma concentrations >100 pg/ml and peak oxygen uptake <25 ml . kg(-1) .min(-1) were recruited. Bisoprolol did not reduce plasma concentrations of soluble tumor necrosis factor receptors (sTNF-R) and interleukin-6 (IL-6) in ACHD patients (before/after: sTNF-R1: 750+/-131/802+/-130; sTNF-R2: 3,693+/-1,043/4,166+/-840; IL-6: 12.94+/-26.03/13.69+/-16.58 pg/ml). Likewise, peak oxygen uptake, right and left ventricular parameters (determined by magnetic resonance imaging) were not improved by bisoprolol treatment.. In contrast to previously observed beneficial effect(s) of beta-blockade in patients with LVD, there were no beneficial therapeutic effects or cytokine reduction in asymptomatic or minimal symptomatic ACHD patients. These data point to a different pathophysiological role of cytokines in ACHD patients with right ventricular dysfunction, as compared to patients with LVD.

Topics: Adrenergic beta-Antagonists; Adult; Bisoprolol; Cytokines; Female; Humans; Interleukin-6; Male; Natriuretic Peptide, Brain; Oxygen Consumption; Placebos; Postoperative Complications; Prospective Studies; Receptors, Tumor Necrosis Factor, Type I; Receptors, Tumor Necrosis Factor, Type II; Tetralogy of Fallot; Treatment Failure; Tumor Necrosis Factor-alpha; Ventricular Dysfunction, Right

Our purpose was to evaluate the effect of a treatment over six months with bisoprolol on the surrogate parameters of N-Terminal-pro brain natriuretic peptide, subsequently to be described as brain natriuretic peptide, peak uptake of oxygen, and ventricular function assessed by magnetic resonance imaging in grown ups and adults who had undergone surgical correction of tetralogy of Fallot.. We designed a prospective, randomized, double-blind, placebo controlled trial. We enrolled 33 patients, aged 30.9 plus or minus 9.5 years in either class 1 or 2 of the grading of the New York Heart Association class with both levels of brain natriuretic peptide greater than 100 pg/ml and a reduced peak uptake of oxygen less than 25 ml/kg/min. During treatment with Bisoprolol, the levels of brain natriuretic peptide increased significantly from 206 plus or minus 95 to 341 plus or minus 250 pg/ml (p< 0.05), and those of atrial natriuretic peptide from 4117 plus or minus 1837 to 5340 plus or minus 2102 fmol/ml (p = 0.0005). These measures remained unchanged in the group of patients receiving the placebo. Peak uptake of oxygen did not differ significantly in either group, nor did treatment have any significant effect on right and left ventricular volumes and ejection fractions as determined by magnetic resonance imaging. The clinical state as judged within the grading system of the New York Heart Association was also unchanged by beta-blockade.. Beta blockade with Bisoprolol seems to have no beneficial effect on asymptomatic or mildly symptomatic patients with right ventricular dysfunction secondary to repaired tetralogy of Fallot with residual pulmonary regurgitation and/or stenosis.

Topics: Adolescent; Adrenergic beta-Antagonists; Adult; Bisoprolol; Double-Blind Method; Drug Administration Schedule; Exercise Tolerance; Female; Follow-Up Studies; Heart Failure; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Tetralogy of Fallot; Treatment Outcome

Accurate estimation of right ventricular (RV) function in patients with repaired tetralogy of Fallot (RTOF) is difficult, partly due to the presence of tricuspid regurgitation and pulmonary regurgitation and/or stenosis. The aim of the present study was to evaluate RV systolic and diastolic function of adult asymptomatic patients with RTOF by means of tissue Doppler imaging (TDI) and brain natriuretic peptide (BNP) values.. 25 adult patients with RTOF and 25 healthy controls were studied. The following echocardiographic measurements were obtained: RV diameter/left ventricular (LV) diameter (RVD/LVD) and systolic (Sa) and diastolic (Ea, Aa) velocities at the RV free wall tricuspid annulus site. Serum BNP levels were measured as well.. Patients with RTOF demonstrated reduced TDI velocities: Sa, 8.16 +/- 1.15 versus 16.43 +/- 1.15 cm/sec (P < .001); Ea, 10.00 +/- 2.18 versus 18.99 +/- 1.00 cm/sec (P < .001); Aa, 5.64 +/- 1.77 vs. 13.69 +/- 0.86 cm/sec (P < .001). Patients with RTOF also had higher BNP levels than controls (85.0 +/- 87.0 vs 5.36 +/- 1.0 pg/mL; P < .001). The increased BNP levels in RTOF patients correlated with the RVD/LVD ratio (r = .521; P < .01).. Our results indicate that although our cohort of patients was asymptomatic, using TDI and BNP allowed us to easily discriminate them from the healthy controls. The ability of TDI to assess ventricular function even in the presence of valvular lesions, as in RTOF patients, makes it a valuable tool in the investigation and follow-up of these patients.

Topics: Adolescent; Adult; Echocardiography, Doppler, Pulsed; Female; Humans; Image Interpretation, Computer-Assisted; Male; Natriuretic Peptide, Brain; Reproducibility of Results; Sensitivity and Specificity; Tetralogy of Fallot; Treatment Outcome; Ventricular Dysfunction, Right

Although widely used in cardiology, relation of heart failure biomarkers to cardiac haemodynamics in patients with CHD (and in particular with pulmonary insufficiency undergoing pulmonary valve replacement) remains unclear. We hypothesised that the cardiac function biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP), soluble suppressor of tumorigenicity 2, and galectin-3 would have significant associations to right ventricular haemodynamic derangements.. Consecutive patients ( n = 16) undergoing cardiac catheterisation for transcatheter pulmonary valve replacement were studied. NT-proBNP, soluble suppressor of tumorigenicity 2, and galectin-3 levels were measured using a multiplex enzyme-linked immunosorbent assay from a pre-intervention blood sample obtained after sheath placement. Spearman correlation was used to identify significant correlations (p ≤ 0.05) of biomarkers with baseline cardiac haemodynamics. Cardiac MRI data (indexed right ventricular and left ventricular end-diastolic volumes and ejection fraction) prior to device placement were also compared to biomarker levels.. NT-proBNP and soluble suppressor of tumorigenicity 2 were significantly correlated (p < 0.01) with baseline mean right atrial pressure and right ventricular end-diastolic pressure. Only NT-proBNP was significantly correlated with age. Galectin-3 did not have significant associations in this cohort. Cardiac MRI measures of right ventricular function and volume were not correlated to biomarker levels or right heart haemodynamics.. NT-proBNP and soluble suppressor of tumorigenicity 2, biomarkers of myocardial strain, significantly correlated to invasive pressure haemodynamics in transcatheter pulmonary valve replacement patients. Serial determination of soluble suppressor of tumorigenicity 2, as it was not associated with age, may be superior to serial measurement of NT-proBNP as an indicator for timing of pulmonary valve replacement.

Topics: Adolescent; Adult; Biomarkers; Cardiac Catheterization; Child; Female; Heart Failure; Heart Valve Prosthesis Implantation; Heart Ventricles; Hemodynamics; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Valve Insufficiency; Tetralogy of Fallot; Young Adult

Tetralogy of Fallot is the most common cyanotic congenital heart disease. Patients with the condition have a high risk of developing chronic kidney disease. Treatment of kidney disease in patients with complex hemodynamics presents unique challenges. However, there are very few reports on the treatment of end-stage renal failure in patients with tetralogy of Fallot.. We present a rare case of peritoneal dialysis in a 47-year-old man with tetralogy of Fallot who had not undergone intracardiac repair. Peritoneal dialysis successfully removed fluids and solutes without adversely affecting the patient's hemodynamics. Our patient was managed with peritoneal dialysis for 5 years before he succumbed to sepsis secondary to digestive tract perforation.. In this paper, we discuss the importance of monitoring acid-base balance, changes in cyanosis, and hyperviscosity syndrome during peritoneal dialysis in patients with tetralogy of Fallot. Lower leg edema and B-type natriuretic peptide level were useful monitoring parameters in this case. This case illustrates that with attention to the patient's unique requirements, peritoneal dialysis can provide successful renal replacement therapy without compromising hemodynamics in patients with tetralogy of Fallot.

Topics: Blalock-Taussig Procedure; Cyanosis; Edema; Headache; Hemodynamics; Hemoglobins; Humans; Kidney Failure, Chronic; Male; Middle Aged; Natriuretic Peptide, Brain; Oxygen Inhalation Therapy; Peritoneal Dialysis; Phlebotomy; Polycythemia; Tetralogy of Fallot

Proper integration of multiple imaging modalities in the routine follow-up of patients with repaired tetralogy of Fallout (TOF) is poorly supported by data. We report our single center comparative study between cardiac magnetic resonance (CMR) and echocardiography to assess equipoise in the clinical utility of these two imaging methods in an unselected consecutive cohort of TOF patients referred to our outpatient clinic.. In this cross-sectional study, repaired TOF patients who underwent CMR and echocardiography within a 4-week period between 2010 and 2011 at our Center were included. Linear regression was used to analyze degree of inter modality correlation. A prediction model tested the association between functional data/probrain natriuretic peptide (Pro-BNP) with CMR.. Fifty patients were included in the study (mean age 31 ± 18 years). The best predictors of right ventricle (RV) ejection fraction at CMR were tricuspid anular plane systolic excursion (tricuspid valve anular plane systolic excursion, R 0.37, P < 0.0001) and RV peak S-wave velocity (R 0.40, P < 0.001). Pro-BNP levels did present weak correlation with New York Heart Association functional class (R 0.31, P < 0.002) and QRS duration (R 0.32, P < 0.002) and a moderate correlation with right atrium area at CMR (R 0.46, P < 0.0001).. We found limited correlation between the two imaging modalities in the evaluation of RV after intracardiac repair of TOF. Pro-BNP level presents moderate correlation with right atrium area measured with echocardiography. Serial CMR evaluations are needed in this patient population, but they may be interchanged by routine echocardiography in particular in patients with normal or stable echocardiographic parameters.

Topics: Adolescent; Adult; Age Factors; Aged; Biomarkers; Cardiac Surgical Procedures; Cross-Sectional Studies; Echocardiography; Female; Heart Failure; Hemodynamics; Humans; Italy; Magnetic Resonance Imaging; Male; Middle Aged; Multimodal Imaging; Natriuretic Peptide, Brain; Peptide Fragments; Pilot Projects; Predictive Value of Tests; Tetralogy of Fallot; Time Factors; Treatment Outcome; Ventricular Function, Left; Ventricular Function, Right; Young Adult

The aim of this study was to temporally measure N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels over a period of 18 months after corrective surgery among children with tetralogy of Fallot (TOF) and to explore how commonly used pharmaceuticals (i.e., spironolactone and digoxin) might affect the normalization pattern. This retrospective study included 136 children with a median age of 7 months who underwent cardiac surgery for TOF. NT-proBNP level was measured at 1, 3, 6, 12, and 18 months after the surgery. Normalization of NT-proBNP was defined as an NT-proBNP level ≤250 pg/ml. The commonly used pharmaceuticals spironolactone and digoxin after discharge were collected. The normalization pattern, normalization time, and potential influence of the pharmaceuticals were determined. The rate of normalization was 24.2% (95% confidence interval [CI] 8.58% to 68.4%) per 100 person-days. Kaplan-Meier survival analysis showed a median normalization time of 517 (95% CI 429.6 to 604.3) days. The children whose NT-proBNP level did not normalize had a significantly higher readmission rate than those whose NT-proBNP level normalized (19.0% vs 2.8%, p = 0.018). Multivariable logistic regression models confirmed that the regular users of spironolactone, alone (odds ratio = 1.45, 95% CI 1.15 to 1.83) or in combination with digoxin (odds ratio = 1.28, 95% CI 1.03 to 1.58), had markedly faster recovery trajectories for measures of NT-proBNP than the irregular users of both. In conclusion, NT-proBNP normalization after cardiac surgery for TOF is a lengthy process, and irregular use of spironolactone could lead to failure in recovery and hospital readmission.

Topics: Biomarkers; Cardiac Surgical Procedures; Female; Follow-Up Studies; Humans; Infant; Male; Natriuretic Peptide, Brain; Peptide Fragments; Postoperative Period; Prognosis; Protein Precursors; Recovery of Function; Retrospective Studies; ROC Curve; Tetralogy of Fallot

Objective To investigate the influence of surgical correction on biomarkers of endothelial dysfunction in children with congenital heart disease and to evaluate anthropometric data. Methods Children with pulmonary hypertension (PH) or Tetralogy of Fallot (TOF) who were scheduled for corrective surgery were enrolled in this prospective study. Age-matched healthy children were included as controls. Demographic, haemodynamic and cardiac ultrasonography data were collected. Blood samples were taken pre-surgery, 24-48 hours post-surgery and again 3-6 months later. Several biomarkers (protein C, soluble platelet selectin [CD62P], soluble endothelium selectin [CD62E], soluble leukocyte selectin [CD62L], plasma von Willebrand Factor [vWF] atrial natriuretic peptide [ANP], brain natriuretic peptide[(BNP] and insulin-like growth factor-1 [IGF-1]) were measured. Results Sixty-three children (32 with PH, 15 with TOF, and 16 controls) were enrolled. No significant differences between the PH and TOF groups were observed in the expression of biomarkers pre- and post-surgery. IGF-1 levels were closely related to anthropometric data, particularly those children with PH. Expression of IGF-1 and weight/height normalized after corrective surgery. Conclusions No significant endothelial dysfunction was observed in children with PH or TOF before or after corrective surgery. Significant retardation of growth, particularly weight, was found before surgery and may be related to IGF-1 suppression.

Topics: Anthropometry; Atrial Natriuretic Factor; Biomarkers; Case-Control Studies; E-Selectin; Female; Humans; Hypertension, Pulmonary; Infant; Infant, Newborn; Insulin-Like Growth Factor I; L-Selectin; Male; Natriuretic Peptide, Brain; P-Selectin; Prospective Studies; Protein C; Tetralogy of Fallot; Ultrasonography; von Willebrand Factor

It is challenging to evaluate aortopathy in congenital heart disease using conventional investigations such as brachial-ankle pulse wave velocity (baPWV). Therefore, we evaluated the cardio-ankle vascular index (CAVI), a dimension of the ascending aorta and plasma transforming growth factor-β1 (TGF-β1) level, in order to find novel noninvasive parameters of aortopathy in adults with repaired tetralogy of Fallot (TOF). Prospectively, we enrolled 42 consecutive adults with TOF (28 patients with repaired TOF were not on ARB, 8 patients with repaired TOF on ARB, 6 patients with no repair or only palliative repair) and 20 age-matched healthy controls. We measured CAVI, baPWV, plasma TGF-β1 level and a diameter of the ascending aorta using echocardiography. The mean age of repaired TOF without ARB were 31.9 ± 9.1 years. An aortic diameter of the ascending aorta, CAVI, and plasma TGF-β1 level were significantly higher in repaired TOF without ARB than those in controls, whereas baPWV did not differ. On a univariate analysis, CAVI, plasma TGF-β1 level and Rastelli procedure were important factors for an aortic diameter of the ascending aorta (r = 0.56, P < 0.01, r = 0.59, P < 0.01, r = 0.39, P < 0.05, respectively) in this population. There was no significant correlation with age, baPWV, NT-pro brain natriuretic peptide (BNP), repair age, shunt duration, aortic regurgitation or right aortic arch. On the other hand, patients with unrepaired or palliative TOF, who had obvious volume overload, showed no significant correlation with CAVI, baPWV or plasma TGF-β1 level. CAVI and plasma TGF-β1 level, not baPWV, correlate to aortopathy in adults with repaired TOF.

Topics: Adult; Ankle Brachial Index; Aorta; Case-Control Studies; Echocardiography; Female; Humans; Japan; Linear Models; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Pulse Wave Analysis; Tetralogy of Fallot; Transforming Growth Factor beta1; Young Adult

The goal of this study was to interrelate N-terminal B-type natriuretic peptide (NT-proBNP) levels and cardiac magnetic resonance imaging-derived ventricular function, mass, and volumes in adults with pulmonary regurgitation after Fallot repair and to evaluate the prognostic relevance of these parameters regarding adverse clinical outcome.. Eighty-one patients (aged 26.3 ± 7.4 years; male sex, 45.7%; New York Heart Association class I, 72.8%; pulmonary valve velocity, < 3 m/s) were included. At baseline cardiac magnetic resonance imaging and NT-proBNP measurements were performed.. During a mean observation time of 6.9 ± 2.6 years, 13 patients (16.1%) had sustained supraventricular arrhythmias or heart failure (2.4 per 100 patient-years). Multivariate Cox analysis identified NT-proBNP, left ventricular (LV) end-systolic volume index and LV ejection fraction, right ventricular (RV) end-diastolic volume index, and tricuspid regurgitation as independent predictors of adverse events. NT-proBNP correlated with LV but not with RV parameters. In receiver operating characteristic curve analysis using significant variables of the multivariate analysis, NT-proBNP was superior to all other parameters to detect patients at risk (area under the curve [AUC], 0.873; 95% confidence interval, 0.772-0.974). LV end-systolic volume index (AUC, 0.734), RV end-diastolic volume index (AUC, 0.645) und tricuspid regurgitation (AUC, 0.747) showed lower diagnostic accuracy.. Even in mildly symptomatic patients with pulmonary regurgitation after Fallot repair NT-proBNP is a strong predictor of adverse outcome. It is rather associated with LV but not with RV impairment. In severe pulmonary regurgitation an increase in the level of NT-proBNP and LV impairment seem to provide additional useful information for the timing of pulmonary valve replacement.

Topics: Adult; Biomarkers; Diastole; Echocardiography; Female; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Longitudinal Studies; Magnetic Resonance Imaging, Cine; Male; Multivariate Analysis; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Pulmonary Valve Insufficiency; Stroke Volume; Systole; Tachycardia, Supraventricular; Tetralogy of Fallot; Tricuspid Valve Insufficiency; Ventricular Dysfunction, Left; Ventricular Dysfunction, Right

B-type natriuretic peptide has been extensively studied in patients with cardiovascular disease, but its impact on the perioperative outcome of patients with cyanotic congenital heart defects is still unclear. We assessed the perioperative changes in B-type natriuretic peptide levels and their correlation with preoperative factors and clinical outcomes in a large homogenous group of patients with tetralogy of Fallot undergoing definitive repair at a tertiary care center.. A prospective study was undertaken in the cardiac operating room and intensive care unit at a single institution; 250 patients with tetralogy of Fallot undergoing intracardiac repair under cardiopulmonary bypass were studied. B-type natriuretic peptide levels were taken at 3 time points and correlated with clinical variables.. Baseline B-type natriuretic peptide levels correlated with the degree of cyanosis in all 4 groups. B-type natriuretic peptide levels at 24 h after admission to the intensive care unit correlated with mortality in the adult subset of patients. B-type natriuretic peptide levels > 290 pg mL(-1) in the intensive care unit predicted an increased probability of adverse clinical outcomes.. We demonstrated a rise in serum B-type natriuretic peptide levels in patients with tetralogy of Fallot undergoing definitive repair on cardiopulmonary bypass. B-type natriuretic peptide levels may be monitored to identify patients with cyanosis at increased risk of an augmented inflammatory response to cardiopulmonary bypass.

Topics: Adolescent; Adult; Biomarkers; Cardiac Surgical Procedures; Cardiopulmonary Bypass; Child; Child, Preschool; Cyanosis; Female; Hospital Mortality; Humans; India; Infant; Male; Natriuretic Peptide, Brain; Postoperative Complications; Predictive Value of Tests; Prospective Studies; Risk Factors; Tertiary Care Centers; Tetralogy of Fallot; Time Factors; Treatment Outcome; Up-Regulation; Young Adult

Brain natriuretic peptide (BNP) levels are elevated in patients with repaired Tetralogy of Fallot (rTOF), the clinical significance of which remains uncertain.. Ninety consecutive adults (≥ 16 years) with rTOF (mean age 32.7 ± 11.3 years, 64% men) were prospectively recruited from a single tertiary centre, together with 15 age-matched and gender-matched controls. Patients with rTOF had elevated BNP (8.9 (5.9-14.6) vs 5.4 (2.2-7.5) pmol/L; p<0.01), and BNP activation was common even in asymptomatic patients. Also, atrial natriuretic peptide (6.9 (4.0-9.9) vs 3.3 (1.0-4.0) pmol/L; p<0.01), endothelin-1 (1.14 (0.94-1.48) vs 0.75 (0.44-0.93) pmol/L; p<0.01) and renin (55.0 (45.5-66.5) vs 18.6 (12.0-22.7) pmol/L; p<0.01) were elevated at baseline compared with controls. Interactions between BNP with endothelin-1, cardiothoracic ratio and right atrial area were evident. Eight deaths occurred over a median follow-up of 10 years. On Cox regression analysis, BNP emerged as a strong predictor of death (HR 1.16 per 10 pmol/L, 95% CI 1.05 to 1.29; p<0.01). Survival receiver operating curve analysis revealed an optimum cut-off of BNP ≥ 15 pmol/L (=52 pg/mL), above which BNP was related to significantly increased mortality (HR 5.40, 95% CI 1.29 to 22.6; p<0.01); absolute mortality at 5 years 19% vs 3% in patients with BNP ≤ 15 pmol/L. BNP was also a predictor of sustained arrhythmia (HR 2.06 per 10 pmol/L, 95% CI 1.32 to 3.21; p<0.05).. Neurohormonal activation is present in adults with rTOF including asymptomatic patients. BNP level ≥ 15 pmol/L is associated with a fivefold increased risk of death. These data suggest that BNP measurement in patients with rTOF should be incorporated in the periodic risk stratification assessment of these patients under lifelong follow-up.

Topics: Adult; Female; Humans; Male; Natriuretic Peptide, Brain; Neurotransmitter Agents; Postoperative Complications; Prognosis; Prospective Studies; Tetralogy of Fallot; Time Factors; Treatment Outcome

Clinicians are currently encountering an increasing number of patients in the long-term period after tetralogy of Fallot (TOF) repair presenting with pulmonary valve regurgitation (PR) or right ventricular (RV) dysfunction. The purpose of this study was to evaluate the clinical utility of the plasma brain natriuretic peptide (BNP) level and consider surgical indications and timing of pulmonary valve replacement (PVR). We examined 33 patients (21 males, 12 females, mean age 14.5 ± 2.8 years) who underwent TOF repair at Kitasato University Hospital. All patients were evaluated using echocardiography and blood sampling. The mean age at the time of initial repair was 1.3 ± 0.7 years. The patients with moderate-severe PR exhibited significantly higher plasma BNP levels than the patients with trivial-mild PR (mean 37.5 ± 33.1 vs. 17.3 ± 6.6 pg/ml, p = 0.013). The mean plasma BNP level with cardiac symptoms was higher than that observed in the patients without any symptoms (71.4 ± 46.1 vs. 25.0 ± 14.0 pg/ml, p = 0.005). The mean BNP level was significantly decreased after PVR (71.3 ± 46.1-26.1 ± 13.2 pg/ml, p = 0.009), and the plasma BNP level was found to be positively correlated with the RV end-diastolic pressure (r = 0.851; p = 0.008). The optimal BNP cut-off value for considering PVR was 32.15 pg/ml (sensitivity, 85.7 %; specificity, 83.3 %). The plasma BNP level may become a useful diagnostic tool for considering the indications and optimal timing of PVR over the long term after TOF repair.

Topics: Adolescent; Cardiac Surgical Procedures; Child; Echocardiography; Female; Heart Valve Prosthesis Implantation; Humans; Male; Natriuretic Peptide, Brain; Pulmonary Valve; Pulmonary Valve Insufficiency; Tetralogy of Fallot; Time Factors; Treatment Outcome

The relationship between plasma levels of N-terminal B-type natriuretic propeptide (NT-proBNP) and parameters of right ventricular (RV) function was evaluated in patients after surgical repair of tetralogy of Fallot (ToF).. 52 children comprised the study group (SG). The control group (CG) included 32 healthy children. Patient histories, measured NT-proBNP levels and transthoracic echocardiography parameters were analysed.. Tissue Doppler imaging (TDI) demonstrated significant differences (p < 0.01) between SG and CG in regard to the following systolic and diastolic function parameters: peak systolic myocardial velocity (S', 5.9 ± 1.6 cm/s vs. 9.8 ± 2.3 cm/s), peak early diastolic velocity (E', 6.6 ± 2.9 cm/s vs. 11.6 ± 3.1 cm/s), and peak atrial diastolic velocity (A', 3.8 ± 1.6 cm/s vs. 6.6 ± 2.8 cm/s). Mean values of peak longitudinal strain (e) were significantly higher (p < 0.01) in SG compared to CG, including basal lateral segment (BL, -32.8 ± 12.1% vs. -51.5 ± 15.5%), medial lateral segment (ML, -23.8 ± 9.5% vs. -40.4 ± 14.9%), and apical lateral segment (AL, -16.9 ± 7.5% vs. -35.8 ± 13.43%). Mean plasma NT-proBNP level also differed significantly (p < 0.01) between SG and CG (286.0 ± 269.2 pg/mL vs. 153.1 ± 170.5 pg/mL, respectively). NT-proBNP levels were significantly higher (p < 0.01) in SG subjects with reduced effort tolerance (639.2 ± 357.1 pg/mL) compared to those with normal effort tolerance (181.8 ± 97.2 pg/mL), and in patients in whom a transannular patch was used for surgical correction (488.9 ± 317.19 pg/mL) compared to those treated without the use of a transannular patch (228.1 ± 217.5 pg/mL). Significant correlations between plasma NT-proBNP level and S' (r = -0.40, p < 0.01), E' (r = -0.50, p < 0.01), BL e (r = 0.36, p < 0.05), and AL e (r = 0.35, p < 0.05) were found.. 1. Increased plasma NT-proBNP levels in patients after surgical repair of ToF are related to RV systolic dysfunction, as determined by the S' wave velocity of the tricuspid annulus and longitudinal strain of the RV. 2. Children after surgical repair of ToF showed increased plasma NT-proBNP levels associated with RV diastolic dysfunction as evaluated by TDI.

Topics: Adolescent; Child; Echocardiography, Doppler; Female; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Postoperative Period; Tetralogy of Fallot; Ventricular Function, Right

Many patients with repaired Tetralogy of Fallot (ToF) have right ventricular (RV) volume overload due to pulmonary regurgitation (PR). We studied the effect of volume overload on global and regional RV and left ventricular (LV) deformation, and their relationships with conventional diagnostic parameters.. In this cross-sectional study, 94 prospectively recruited ToF patients (61% male, age 32.8 ± 9.5 years, age at repair 1.9 [0.8-5.7] years, 39% pulmonary homograft) and 85 healthy controls of similar age and sex underwent echocardiography and electrocardiography. In a subset of patients, cardiac magnetic resonance imaging, bicycle ergometry, and NT-proBNP measurement were performed within the same day. With speckle-tracking echocardiography, we analysed peak systolic global longitudinal strain (GLS), segmental longitudinal strain and strain rate of the RV free wall, LV lateral wall, and septum. Patients had a lower RV free wall strain than controls (-18.1 ± 4.5 vs. -26.5 ± 4.5%, P < 0.001), especially at the apical segment (-15.9 ± 7.4 vs. -28.2 ± 7.7%, P < 0.001), and lower RV strain rate. LV GLS was also lower (-17.4 ± 2.5 vs. -19.6 ± 1.9%, P < 0.001), mainly due to the interventricular septum. Patients with PR >25% had higher LV GLS and RV free wall strain than patients with PR ≤25% (P = 0.004, P = 0.039, respectively). No relationships were found with NT-proBNP or exercise capacity.. RV free wall strain and strain rate are decreased in adults late after ToF repair, especially at the apical segment suggesting that apical function is most affected in these RVs. Regarding the LV, septal strain is decreased indicating that RV dysfunction adversely affects LV function, probably by mechanical coupling of the ventricles.

Topics: Adult; Biomarkers; Cross-Sectional Studies; Echocardiography; Electrocardiography; Exercise Test; Female; Humans; Magnetic Resonance Imaging; Male; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Tetralogy of Fallot; Ventricular Dysfunction, Left; Ventricular Dysfunction, Right

This study aimed to evaluate biventricular function, brain natriuretic peptide levels, respiratory function test and 6 minute walking test (6MWT) in children with repaired tetralogy of Fallot (TOF), and analyse the correlation between these variables and clinical status.. Twenty-five children (14 boys, 11 girls; aged 6 to 17 years) with repaired TOF (Group 1) and 25 age-sex matched healthy controls (Group 2) were enrolled in the study. Tissue Doppler echocardiography, respiratory function test, 6MWT distance and brain natriuretic peptide levels were measured.. Mean ages of the children at TOF corrective surgery and at study time were 5.1±3.5 years and 11.6±2.7 years respectively. The duration between palliative operation and corrective surgery was 4.3±2.0 years, and the follow-up period after corrective surgery was 6.3±3.0 years. The right ventricular and left ventricular myocardial performance indices (MPIs), and isovolumic relaxation and contraction times were significantly higher in Group 1 than in Group 2 (p<0.01). Spirometry displayed significantly reduced forced vital capacity (FVC), forced expiratory volume in one second (FEV1), forced expiratory flow 25-75% (FEF25-75) and inspirational capacity in Group 1 compared to Group 2 (p<0.01). In Group 1, 6MWT distances were significantly lower than in Group 2 (p=0.001). Right ventricular MPI is correlated with FEV1, FVC and 6MWT distance in the current study.. The children with repaired TOF had impaired ventricular and pulmonary functions. Hence, right ventricular MPI along with FEV1, FVC and 6MWT distance may be useful in the follow-up of children with repaired TOF.

Topics: Adolescent; Case-Control Studies; Child; Cross-Sectional Studies; Echocardiography; Exercise Test; Female; Humans; Male; Natriuretic Peptide, Brain; Pulmonary Valve Insufficiency; Spirometry; Tetralogy of Fallot; Ventricular Dysfunction, Left; Ventricular Dysfunction, Right

To explore changes of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) level in children having undergone radical operation of tetralogy of Fallot (TOF) and its clinical significance.. 52 cases of children with TOF hospitalized in our hospital from October 2011 to April 2013 were chosen, and they were all treated with radical operation of TOF. Levels of plasma NT-proBNP in these children were measured before the operation, and 3h, 12h, 48h, 1 week, 1 months, and 3 months after the operation. The cardiac color supersonic diagnostic set was used to examine pulmonary artery transvalvular pressure gradient, right ventricular end-diastolic volume (RVEDV), left ventricular ejection fraction (LVEF), and right ventricular Tei index.. (1) 3h after the operation, the level of NT-proBNP gradually rose and reached its peak 48h after the operation, which was markedly higher than the level before the operation (p < 0.01), yet the levels measured 1 month and 3 months after the operation were lower than the level before the operation (p < 0.05). (2) 1 week after the operation, NT-proBNP level, pulmonary artery transvalvular pressure gradient, and RVEDV of the group with right ventricular dysfunction were markedly higher than those of the group with normal right ventricular function (p < 0.05). (3) 3 months after the operation, levels of plasma NT-proBNP of children in the severe reflux group and moderate reflux group were markedly higher than those in the slight reflux group (p < 0.05); levels of plasma NT-proBNP of children in the severe reflux group were markedly higher than those of the slight reflux group (p < 0.05) 1 week or 3 months after the operation.. Changes of the NT-proBNP level during early stage after radical operation of children's TOF were in line with changes of the right ventricular function and could be regarded as an objective indicator for evaluating the right ventricular function.

Topics: Biomarkers; Child, Preschool; Female; Humans; Infant; Male; Natriuretic Peptide, Brain; Tetralogy of Fallot; Ultrasonography

Early and accurate noninvasive means of identifying right ventricular (RV) dysfunction in children with tetralogy of Fallot (TOF) are needed. RV function was examined using tissue Doppler imaging (TDI), strain rate (SR), and strain analysis (SA) in children before (N = 37) and after (6-12 months; N = 32) TOF repair, and in a control group of children (N = 37). Plasma concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP) and matrix metalloproteinase 9 (MMP-9) were measured. TDI, SR, and SA revealed that RV systolic and diastolic function indices were lower preoperatively in the TOF group compared with the control group, and did not improve after TOF repair. Plasma NT-proBNP concentrations were significantly higher in the TOF group pre- and postoperatively compared with the control group. In the preoperative TOF group, NT-proBNP concentration was significantly correlated with peak systolic SR and systolic strain in the mid segments of RV free wall. Plasma MMP-9 concentrations were significantly increased in the preoperative TOF group compared with the control group, and significantly correlated with plasma NT-proBNP and logNT-proBNP concentrations. RV function correlated with plasma NT-proBNP concentrations in children with TOF. Assessment of this noninvasive measure may help identify RV dysfunction in patients with TOF before they become clinically symptomatic.

Topics: Child; Child, Preschool; Female; Heart Ventricles; Humans; Infant; Infant, Newborn; Male; Matrix Metalloproteinase 9; Natriuretic Peptide, Brain; Peptide Fragments; Perioperative Period; Tetralogy of Fallot; Ventricular Dysfunction, Right

Left ventricular (LV) dysfunction is a major determinant of late adverse clinical outcome in adult patients with tetralogy of Fallot (ToF). Therefore, early detection is important. Speckle-tracking echocardiography (STE) has emerged as a quantitative technique to assess LV function. The aim of this study was to evaluate LV rotation and twist with STE in adult ToF patients and their association with right ventricular (RV) and LV dimensions and function, exercise capacity, and NT-proBNP level.. Eighty-two ToF patients and 56 healthy controls matched for age and gender underwent echocardiography, electrocardiography, cardiac magnetic resonance imaging (CMR), bicycle ergometry, and NT-proBNP measurement. For STE, short-axis parasternal views were obtained at the LV base and apex. We analysed LV apical and basal rotation curves and calculated LV twist.. Of the 82 ToF patients (55% male, age 33 ± 10 years, 98% NYHA I), 58 (71%) had normal twist, but lower than the controls [12.5 (IQR: 6.6) vs. 16.9 (IQR: 8.2) degrees, P = 0.002] mainly due to decreased apical rotation. Twenty-one (26%) patients had abnormal apical rotation which was associated with larger LV dimensions and decreased systolic biventricular function. Multivariable regression analyses showed positive relations of LV twist with biventricular systolic function measured with echocardiography as well as CMR.. The majority of adults with corrected ToF show a reduced LV twist. Strikingly, one-quarter of these patients have an abnormal apical rotation which is associated with decreased systolic LV and RV function. These findings suggest that abnormal apical rotation is a new objective diagnostic criterion for detection of ventricular dysfunction.

Topics: Adult; Biomarkers; Case-Control Studies; Echocardiography; Electrocardiography; Exercise Test; Female; Humans; Image Interpretation, Computer-Assisted; Male; Natriuretic Peptide, Brain; Peptide Fragments; Rotation; Tetralogy of Fallot; Ventricular Dysfunction, Left

Atrial enlargement may reflect ventricular diastolic dysfunction. Although patients with tetralogy of Fallot (TOF) have been studied extensively, little is known about atrial size and function. We assessed bi-atrial size and function in patients after TOF repair, and related them to biventricular systolic and diastolic function, and clinical parameters.. 51 Patients (21 ± 8 years) and 30 healthy controls (31 ± 7 years) were included and underwent magnetic resonance imaging to assess bi-atrial and biventricular size, systolic and diastolic function. Patients also underwent exercise testing, and N-terminal prohormone brain natriuretic peptide (NT-proBNP) assessment.. In patients, right atrial (RA) minimal volume (34 ± 8 ml/m(2) vs. 28 ± 8 ml/m(2), p=0.001) and late emptying fraction were increased; RA early emptying fraction was decreased. Patients had longer right ventricular (RV) deceleration time (0.24 ± 0.10 vs. 0.13 ± 0.04, p<0.001), reflecting impaired RV relaxation, and larger RV volumes. Patients with end-diastolic forward flow (EDFF) had larger RA and RV size, abnormal RA emptying, higher NT-proBNP levels, higher VE/VCO2 slope (ventilatory response to carbon dioxide production), and the most abnormal LV diastolic function (impaired compliance). Patients with abnormal RA emptying (reservoir function <30% and pump function >24%) had higher NT-proBNP levels and worse exercise capacity. RA minimal volume was associated with RV end-diastolic volume (r=0.35, p=0.013).. In TOF patients with moderate RV dilatation, abnormal bi-atrial function and biventricular diastolic dysfunction are common. Abnormal RA emptying was associated with signs of impaired clinical condition, as was the presence of EDFF. These parameters, together with RA enlargement, could serve as useful markers for clinically relevant RV diastolic dysfunction.

Topics: Adolescent; Adult; Atrial Function, Right; Female; Follow-Up Studies; Heart Atria; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Prospective Studies; Tetralogy of Fallot; Ventricular Dysfunction, Right; Young Adult

B-type natriuretic peptide is used in the diagnosis, risk stratification, and management of adult patients with cardiac disease. However, its use in infants with congenital heart disease has been limited, particularly in the perioperative period. Our objective was to determine the alterations in perioperative B-type natriuretic peptide levels and their predictive value on postoperative outcomes, in infants undergoing congenital heart surgery.. We prospectively enrolled 115 patients: 24 with univentricular heart disease undergoing a modified Norwood procedure, 11 with d-transposition of the great arteries, 55 with hemodynamically important left-to-right shunt, and 25 with tetralogy of Fallot undergoing primary repair. Clinical data and B-type natriuretic peptide samples were collected before and 2, 12, and 24 hours after cardiopulmonary bypass. Univariate analysis and multivariate linear regression analysis were performed.. The perioperative B-type natriuretic peptide levels were lesion specific. Patients with d-transposition of the great arteries and univentricular heart disease had high preoperative B-type natriuretic peptide levels that decreased postoperatively, and those with hemodynamically important left-to-right shunts and tetralogy of Fallot had lower preoperative levels that increased during the first 12 hours postoperatively. The patients with univentricular heart disease with an adverse outcome had a significantly greater 24-hour B-type natriuretic peptide level than those without (P < .05). Those with hemodynamically important left to right shunts and an adverse outcome had a greater 12-hour B-type natriuretic peptide level than those without (P < .05). A 12-hour postoperative/preoperative ratio greater than 45 was 100% sensitive and 82% specific for an adverse outcome in the patients with tetralogy of Fallot.. The perioperative changes in B-type natriuretic peptide levels and their ability to predict outcomes are lesion-specific. Characterization of these changes might be useful in caring for infants after congenital heart surgery.

Topics: Biomarkers; Cardiac Surgical Procedures; Female; Heart Defects, Congenital; Heart Ventricles; Hemodynamics; Humans; Infant; Infant, Newborn; Lactic Acid; Male; Multivariate Analysis; Natriuretic Peptide, Brain; Norwood Procedures; Perioperative Period; Predictive Value of Tests; Prospective Studies; Risk Factors; Sensitivity and Specificity; Tetralogy of Fallot; Time Factors; Transposition of Great Vessels; Treatment Outcome

Patients after surgical repair of tetralogy of Fallot (TOF) may experience various complications that result in neurohormonal activation, including plasma B-type natriuretic peptide (BNP) elevation. Right ventricular (RV) dilation is a frequent complication, and few treatments are available. This study aimed to identify the factor or factors leading to BNP elevation and to clarify the effects of angiotensin-converting enzyme inhibitor (ACE-I) on changes in BNP levels in patients with repaired TOF. Plasma BNP levels and hemodynamic data derived from cardiac catheterization were analyzed. In addition, longitudinal BNP levels and ACE-I dosages were analyzed for patients administered ACE-I. For 31 patients with repaired TOF, who mainly had RV dilation, log BNP levels were significantly correlated with the RV end-diastolic volume index (P = 0.02) as well as ventricular volume and pressure (P < 0.01). For 11 patients medicated with ACE-I, BNP levels were significantly lower at the time of maximal ACE-I dosage than at the time of minimal dosage (P < 0.01). Furthermore, BNP levels decreased as the ACE-I dosage per body weight increased (P < 0.01). In conclusion, elevation of BNP in patients after TOF repair could reflect volume and pressure load in the RV end-diastolic phase, and ACE-I may reduce BNP levels in a dose-dependent manner.

Topics: Angiotensin-Converting Enzyme Inhibitors; Child; Child, Preschool; Dose-Response Relationship, Drug; Female; Humans; Male; Natriuretic Peptide, Brain; Retrospective Studies; Tetralogy of Fallot; Time Factors

Improved medical techniques have allowed most women with repaired tetralogy of Fallot (TOF) to reach childbearing age. The predictors of adverse events and the effects of pregnancy on cardiac function have not been clearly described in these patients.. In the present study we retrospectively reviewed 40 deliveries in 25 patients with repaired TOF. There were 23 patients in New York Heart Association (NYHA) class I, and 2 in classes II-III before pregnancy. The mean age at delivery was 29.1 years and the mean gestational period was 37.8 weeks. Seven pregnancies (17.5%) in 7 patients were complicated with cardiac events such as a decline in NYHA class and arrhythmia. History of ablation and the baseline cardiothoracic ratio on chest radiography were predictors of adverse events. Peak plasma brain natriuretic peptide (BNP) level after the second trimester was higher in patients with cardiac events. Left ventricular size and contraction did not change from before to after pregnancy, but the right ventricle was enlarged at 6 months after delivery.. Many of the pregnancies in women with repaired TOF were successful. However, careful management is required for some patients and the BNP level may be a useful marker to identify these patients. Because the right heart tended to be enlarged in the late postpartum period, pregnancy may also affect the long-term prognosis of patients with repaired TOF.

Topics: Adult; Biomarkers; Cardiac Surgical Procedures; Chi-Square Distribution; Female; Gestational Age; Humans; Hypertrophy, Right Ventricular; Japan; Natriuretic Peptide, Brain; Pregnancy; Pregnancy Complications, Cardiovascular; Pregnancy Outcome; Retrospective Studies; Risk Assessment; Risk Factors; Tetralogy of Fallot; Time Factors

B-type natriuretic peptide (BNP) response early after a tetralogy of Fallot's repair remains unclear. BNP was measured pre- and post-operatively (immediately, day 1) in 18 children undergoing corrective repair with concurrent echocardiography (pre-, post-op day 1) to assess right ventricular (RV) systolic dysfunction, restrictive physiology, wall motion and pulmonary regurgitation (PR). In the first 24 h postoperatively, BNP rose acutely in all patients (mean 34.9 vs 144.4 vs 716.9 pg/ml at pre-op, days 0 and 1; P < 0.001). Immediate postoperative BNP correlated with preoperative haematocrit (rho = 0.52, P = 0.03) and inversely with preoperative oxygen saturation (rho = -0.63, P = 0.007). All patients showed reduced RV systolic function and abnormal wall motion with at least moderate PR in six patients (33.3%) and restrictive physiology in four (24%). Subsequent BNP expression (post-op day 1) correlated with a low RV fractional area change (rho = -0.51, P = 0.04), high oxygen extraction ratio (rho = 0.56, P = 0.02) and high central venous pressure (rho = 0.79, P < 0.001). The LV function and wall motion remained preserved in all patients. The mechanism of BNP expression is likely to be multi-factorial in the presence of a complex postoperative RV physiology in tetralogy of Fallot. An acute BNP response in the early postoperative period reflects an important physiological role and may be used as an adjunct biomarker to assess the RV function.

Topics: Biomarkers; Child, Preschool; Echocardiography, Doppler; Exercise Test; Female; Follow-Up Studies; Heart Ventricles; Humans; Infant; Male; Myocardial Contraction; Natriuretic Peptide, Brain; Postoperative Period; Prognosis; Prospective Studies; Systole; Tetralogy of Fallot; Time Factors; Ventricular Function, Right

To evaluate the utility of plasma BNP measurement in the long term follow-up of patients with surgically repaired tetralogy of Fallot (TOF).. From 2002 to 2008, plasma BNP concentration was measured in 130 patients with TOF at the age of mean 16.1+/-7.1 years and mean 13.0+/-6.5 years after surgically repair. BNP levels were compared to age and gender-specific normal values, results of exercise testing, clinical, electrocardiographic, and echocardiographic data.. BNP was <200 pg/ml in all and elevated in 60% of patients. Higher values were found in females (p=0.001), in patients waiting for pulmonary valve replacement (p<0.001), and in NYHA class II compared to NYHA I patients (p=0.012) with an inverse correlation between BNP and exercise time (r=-0.59, p<0.001). BNP was correlated with right ventricular dilatation (r=0.29, p=0.005) and severity of both tricuspid (r=0.22, p=0.015) and pulmonary regurgitation (r=0.20, p=0.029). Longitudinal data revealed increasing BNP levels before (p=0.04) and a BNP decrease after pulmonary valve replacement (p=0.03), but no change in patients without surgery.. In patients with surgically repaired TOF, plasma BNP is significantly correlated with right ventricular volume load. In clinical practice a considerable overlap limits the estimation of right ventricular volume load by BNP, but longitudinal evaluation helps to appoint the appropriate timing of pulmonary valve replacement.

Topics: Adolescent; Adult; Biomarkers; Child; Child, Preschool; Echocardiography; Electrocardiography; Exercise Test; Female; Follow-Up Studies; Humans; Male; Natriuretic Peptide, Brain; Pulmonary Valve Insufficiency; Reproducibility of Results; Retrospective Studies; Tetralogy of Fallot; Ventricular Function, Right; Young Adult

Although the residual lesions after surgical correction of tetralogy of Fallot (TOF) can be evaluated by Doppler echocardiography (DE), the relation of DE parameters with the proBNP level, a potential biomarker of right ventricle overload, is not well known. The objective of this study was to evaluate the DE parameters and their relation to proBNP levels.. proBNP plasma level and Doppler echocardiography parameters were obtained on the same day in 49 patients later after repair of TOF (mean age of 14.7 years, 51% female, mean PO time of 9.5 years). The DE parameters studied were the dimensions of the right atrium (RA) and ventricle (RV), RV diastolic and systolic function, and residual pulmonary lesions. The relation between them and proBNP levels were analyzed and the cutoff values of DE parameters for elevated proBNP determined.. proBNP was elevated in 53% and correlated with RV diastolic diameter (r = 0.41; P = 0.003), RA longitudinal (r = 0.52; P = 0.0001) and transversal (r = 0.47; P = 0.001) diameters, pressure half time of pulmonary regurgitation (PR) velocity (PHT) (r =-0.42; P = 0.005), and the PR index (r =-0.60; P < 0.001). By multivariate analysis, the PR index (r =-597; P = 0,001; CI: -913.2 to -280.8) and RA longitudinal (r = 7.74; P < 0,001; CI 4.18 to 11.31) were independent predictors of elevated proBNP. PHT lower than 64 msec (0.76) and PRi lower than 0.65 (0.81) had the best accuracy for elevated proBNP.. proBNP may be increased in patients after surgical repair of TOF, correlated with the size of right cardiac chambers and the severity of PR.

Topics: Adolescent; Area Under Curve; Biomarkers; Echocardiography, Doppler; Female; Heart Atria; Heart Ventricles; Humans; Male; Natriuretic Peptide, Brain; Postoperative Period; Predictive Value of Tests; ROC Curve; Sensitivity and Specificity; Severity of Illness Index; Tetralogy of Fallot; Ventricular Dysfunction, Right

Early detection of right ventricular (RV) dysfunction is essential in the assessment of patients with repaired tetralogy of Fallot (TOF). This study aimed to assess latent RV dysfunction in asymptomatic patients with TOF and to determine the predictive value of B-type natriuretic peptide (BNP). Pressure-volume loops were recorded for 16 young patients (New York Heart Association class 1 or Ross class 0; median age, 14.2 years) using the conductance catheter technique. All the patients had RV dilation secondary to pulmonary regurgitation after surgical repair of TOF. Indexes of RV function were derived at baseline level and during dobutamine infusion. Contractility was calculated by the slope of the end-systolic pressure-volume relation (ESPVR). An increase in ESPVR during dobutamine infusion was considered to indicate contractile reserve as a marker for latent RV dysfunction. The median ESPVR significantly increased from 0.32 mmHg/ml (0.13-0.72 mmHg/ml) at baseline to 0.57 mmHg/ml (0.24-1.55 mmHg/ml) during dobutamine infusion (p = 0.005). However, for five patients, no relevant increase in contractility was found, indicating impaired RV contractile reserve. There was only a weak inverse correlation between impaired contractile reserve and BNP (r = -0.28). Even asymptomatic patients with only a mildly enlarged right ventricle can have impaired RV function. Early RV dysfunction cannot be predicted accurately with BNP.

Topics: Adolescent; Biomarkers; Cardiac Catheterization; Child; Child, Preschool; Female; Hemodynamics; Humans; Infant; Male; Natriuretic Peptide, Brain; Statistics, Nonparametric; Tetralogy of Fallot; Ventricular Dysfunction, Right

To assess biventricular functional reserve (FR), NT-proBNP levels and exercise performance, in relation to right ventricular volume in patients with pulmonary regurgitation (PR) after repair of tetralogy of Fallot (TOF) at young age.. In 53 TOF patients (maximum age at repair 2.0 years, interval since repair 15 (5) years) without residual lesions except PR, biventricular FR (derived from magnetic resonance imaging with dobutamine stress), NT-proBNP levels, maximal workload, and peak oxygen uptake were assessed.. Mean right ventricular end-diastolic volume was 140(38) ml/m(2). Median pulmonary regurgitant fraction was 37% (range 0-57%). Biventricular systolic stress response was normal: mean (SD) ESV decreased (DeltaRVESV -17(8) ml/m(2), DeltaLVESV -11(5)), SV increased (DeltaRVSV +12(9) ml/m(2), DeltaLVSV +9(6)), FR was positive in all (RV-FR +11(5)%, LV-FR +13(6)). No serious adverse effects to dobutamine were encountered. NT-proBNP was increased in 2 patients. Median level was 10 pmol/L (range 2-42). NT-proBNP correlated with PR-percentage but not with right ventricular size. High-risk levels of NT-proBNP indicated a smaller RV-FR and a smaller decrease of biventricular ESV. Mean (SEM) VO2(max) was 96(3)%, mean Workload(max) 89(2)% of predicted.. At mid to long term follow-up overall NT-proBNP levels are normal and biventricular functional reserve and exercise tolerance are well preserved in TOF repaired at young age, irrespective of RV volume. This questions the validity of isolated PR or RV volume criteria for pulmonary valve replacement in this group. Low-dose dobutamine stress testing is well tolerated and may be a useful additional tool for clinical decision making.

Topics: Adolescent; Adult; Age Factors; Child; Cohort Studies; Echocardiography, Doppler; Exercise Test; Female; Follow-Up Studies; Humans; Magnetic Resonance Imaging; Male; Natriuretic Peptide, Brain; Peptide Fragments; Recovery of Function; Stroke Volume; Tetralogy of Fallot; Ventricular Dysfunction, Right; Young Adult

Topics: Child; Coronary Circulation; Heart Bypass, Right; Heart Defects, Congenital; Heart Septal Defects, Ventricular; Humans; Infant; Natriuretic Peptide, Brain; Postoperative Period; Tetralogy of Fallot

The global myocardial function in patients after repair of tetralogy of Fallot (TOF) can be assessed by cardiovascular magnetic resonance (CMR) and measurement of B-type natriuretic peptides. Two-dimensional echocardiography-derived strain and strain rate (2D strain) facilitate the assessment of regional myocardial function. We evaluated myocardial function in 16 children with residual severe pulmonary valve regurgitation and right ventricular (RV) volume overload after TOF repair before, 1 month after, and 6 months after pulmonary valve replacement (PVR). In 2D strain echocardiography preoperatively, the longitudinal systolic RV strain was reduced (p < 0.05). One month after PVR, longitudinal systolic RV strain decreased further (p < 0.05), while systolic and early diastolic radial left ventricular strain and strain rate increased (each p < 0.05), followed by a return toward preoperative values after 6 months. Six months after PVR, preoperatively elevated RV end-diastolic volume (p < 0.01) assessed by CMR and N-terminal pro-B-type natriuretic peptide (p < 0.05) decreased. In conclusion, the impairment of the regional myocardial after TOF repair and transient changes after PVR can be subtly analyzed by 2D strain echocardiography in addition to the established assessment of myocardial function with CMR and measurement of B-type natriuretic peptides.

Topics: Adolescent; Child; Echocardiography; Female; Heart Ventricles; Humans; Magnetic Resonance Imaging; Male; Natriuretic Peptide, Brain; Peptide Fragments; Pulmonary Valve Insufficiency; Tetralogy of Fallot; Young Adult

Right ventricular (RV) volume overload secondary to pulmonary regurgitation contributes to long-term morbidities in patients after tetralogy of Fallot (TOF) repair. We tested the hypothesis that plasma brain natriuretic peptide (BNP) levels relate to RV volume overload, pulmonary regurgitation, and exercise capacity in adolescents after TOF repair.. We assessed the RV function echocardiographically and plasma BNP levels in 32 postoperative TOF patients aged 14.7+/-3.1 years and 20 age-matched controls. Eighteen patients further underwent cardiovascular magnetic resonance imaging and 26 had exercise testing.. Compared with controls, patients had significantly higher BNP levels (p=0.027), greater indexed RV end-diastolic dimension (p<0.001), increased RV myocardial performance index (p=0.005), and reduced tricuspid annular systolic velocity (p=0.008). Multivariate analysis identified indexed RV end-diastolic dimension as the only significant determinant of plasma BNP levels (beta=0.69, p<0.001). Plasma BNP levels correlated positively with indexed RV end-diastolic volume (r=0.6, p=0.009) and pulmonary regurgitant fraction (r=0.54, p=0.026), and negatively with exercise duration (r=-0.45, p=0.021), peak oxygen consumption (r=-0.43, p=0.03), and minute ventilation at maximal exercise (r=-0.52, p=0.006). Multivariate analysis demonstrated BNP levels (beta=-0.43, p=0.034) and body mass index (beta=-0.40, p=0.036) to be independent predictors of peak oxygen consumption. No relations were found between BNP levels and RV myocardial performance index, tricuspid annular velocities and RV ejection fraction.. In adolescent patients after TOF repair, plasma BNP levels relate to RV volume overload, pulmonary regurgitation and exercise capacity.

Topics: Adolescent; Child; Cohort Studies; Exercise Test; Female; Humans; Male; Natriuretic Peptide, Brain; Tetralogy of Fallot; Ventricular Dysfunction, Right; Ventricular Function, Right

Define the profile of NT-proBNP values in asymptomatic adult patients after radical correction of Tetralogy of Fallot (TOF) and identify links between possible increase in NT-proBNP and residual echocardiographic findings.. NT-proBNP samples were taken from and a detailed echocardiographic examination was performed in 21 adult stabilised patients after radical correction of TOF in childhood. The results were submitted for statistical analysis.. The incidence of low values of the S wave < 11.5 cm/s of tricuspid anulus evaluated by tissue Doppler echocardiography (TDI) (P < 0.05) was significantly higher in patients with NT-proBNP > 125 pg/ml. All patients with impaired right ventricular diastolic filling evaluated by tissue Doppler echocardiography (E' / A' < 1 ) had higher values of NT-proBNP (NS). Other echocardiographic parametres did not show any dependence on NT-proNBP values, including the morphology or atrial defects in the right heart sections which are most conspicuous in an echocardiographic examination.. Asymptomatic patients after radical correction of TOF have higher values of NT-proBNP (167.95 +/- 91.75 pg/ml). At the same time, the increase closely correlates with the detection of a global right ventricle systolic dysfunction evaluated by S (TDI). On the other hand, there is often no correlation between highly conspicuous changes in the morphology of the right heart compartments or residual or postincision defects of the pulmonary valve on the one hand and increased NT-proBNP on the other. The S measurement has the potential to become routine examination in patients after radical correction of TOF for timely detection of right ventricular systolic dysfunction. Precise prognostic and primarily therapeutic impact of the pathologic finding still needs to be determined.

Topics: Adult; Biomarkers; Echocardiography, Doppler; Female; Humans; Male; Middle Aged; Natriuretic Peptide, Brain; Peptide Fragments; Protein Precursors; Tetralogy of Fallot; Ventricular Dysfunction, Right

Topics: Adrenergic beta-Antagonists; Bisoprolol; Child; Exercise Tolerance; Heart Failure; Humans; Natriuretic Peptide, Brain; Peptide Fragments; Research Design; Tetralogy of Fallot; Treatment Outcome

Surgical repair of tetralogy of Fallot may leave the patient with pulmonary regurgitation, causing eventual right ventricle dilatation and dysfunction. Predicting clinical deterioration may help to determine the best timing for intervention.. To assess whether the clinical and humoral status of patients in the second decade after repair of ToF is worse than that of patients in the first decade after repair.. Twenty-one patients with repaired ToF underwent clinical assessment, electrocardiogram, echocardiogram and measurement of plasma B-type natriuretic peptide and N-terminal pro-BNP as well as the 6 minute walk distance test. Patients were divided into two groups: group A - less than 10 years after repair (n=10, age < 12 years old), and group B - more than 10 years after repair (n=11, age > 12 years old). The age at repair was similar in both groups.. In all but one patient the distance in the 6 min walk test was less than the minimum for age. RV end-diastolic volume and the 6 min walk test correlated with age. NT-proBNP levels were significantly higher in the ToF group compared to 26 healthy controls (P < 0.0001) and were inversely correlated with RV ejection fraction. Comparison of the two groups showed no difference in RV end-diastolic volume indexed for body surface area, pulmonary regurgitation severity, right or left ventricular myocardial performance index, RV ejection fraction, QRS duration, or 6 min walk indexed to minimum for age.. In this group of patients with similar age at operation and pulmonary regurgitation severity, most clinical, echocardiographic and humoral parameters were not worse in the second decade after repair of ToF. These data suggest that very early pulmonary valve replacement may not be of benefit.

Topics: Adolescent; Adult; Analysis of Variance; Child; Child, Preschool; Echocardiography; Electrocardiography; Exercise Test; Female; Humans; Male; Natriuretic Peptide, Brain; Postoperative Complications; Pulmonary Valve Insufficiency; Statistics, Nonparametric; Tetralogy of Fallot; Treatment Outcome

Adult patients after surgical repair of Fallot's tetralogy usually present with satisfactory exercise capacity years after the original procedure, though they never tolerate as high levels of exercise as their healthy counterparts. The aim of the study was to assess exercise capacity with cardiopulmonary stress test and BNP levels in adult survivors of surgical repair of Fallot's tetralogy. We studied 60 patients with no or only mild symptoms (including 29 males), at the mean age of 27.6+/-8.2 years at the time of follow-up screening, operated on at the age of 7.5+/-5.3 years. In 34 patients moderate to severe pulmonary regurgitation (PR+) was observed. Control group consisted of 28 healthy volunteers (13 males), aged 28.7+/-5.1 years. Peak oxygen uptake (VO2) in studied group was found to be significantly lower than in control group (24.7+/-5.5 vs. 36.6+/-7.6 ml/kg/min, p=0.00001), VE/VCO2 slope, the marker of respiratory effort, was higher in surgical treatment group as compared to the control group (36.5+/-6.3 vs. 29.7+/-4.7, p=0.004). In patients with PR+, peak VO2% was higher than in PR- individuals (69.6+/-11.8% vs. 58.5+/-12.1%, p=0.0005). The BNP concentration in the studied group (34.8+/-27.1 pg/ml) was higher than in healthy subjects (11.5+/-6.5 pg/ml, p=0.00001). Levels of BNP correlated inversely with peak VO2 (r=-0.286, p=0.03), FVC (r=-0.265 p=0.04) and positively with VE/VCO2 (r=0.361, p=0.005). Additionally the levels of BNP correlated positively with the age of patients at the time of surgical repair (r=0.250, p=0.04). We concluded that exercise capacity in adults after repair of Fallot's tetralogy, especially those PR+, was lower than in healthy volunteers. Concentrations of BNP in surgical treatment survivors were higher and correlated well with cardiopulmonary stress study parameters.

Topics: Adolescent; Adult; Case-Control Studies; Child; Child, Preschool; Exercise; Exercise Test; Female; Humans; Infant; Male; Middle Aged; Natriuretic Peptide, Brain; Oxygen Consumption; Respiratory Function Tests; Tetralogy of Fallot; Ventricular Function, Right

The aim of this study was to analyze the effect of pressure and/or volume overload on right ventricular (RV) function and brain natriuretic peptide (BNP) levels in patients with surgically corrected congenital heart disease. Forty-two consecutive patients aged 17 to 57 years (median 30) with congenital heart disease (32 with tetralogy of Fallot and 10 with pulmonary stenosis) were examined. The RV systolic pressure was estimated using Doppler echocardiography. Cardiovascular magnetic resonance imaging was used to obtain the RV volumes, ejection fraction (EF) and corrected EF (cEF). Plasma BNP levels were determined by immunoradiometric assay. Patients were categorized as having volume overload when pulmonary regurgitation was > or =10% and pressure overload when the RV systolic pressure was >40 mm Hg. Patients with RV volume overload had a lower RVEF compared with patients with pressure overload (p = 0.02) and lower left ventricular EF (p <0.001). BNP was higher in patients with volume overload than in patients with pressure overload (p = 0.002). BNP correlated with pulmonary regurgitation, RVEF, RV cEF, and left ventricular EF. In linear regression analysis, RV cEF was an independent predictor for BNP, after adjustment for age. Without the parameter of RV cEF in the regression model, pulmonary regurgitation and RVEF were independently associated with BNP level, after adjustment for age. In conclusion, patients with RV volume overload had higher BNP levels and lower RV function than patients with RV pressure overload. BNP levels were independently associated with the degree of RV volume overload and RV function.

Topics: Adolescent; Adult; Cardiac Volume; Female; Follow-Up Studies; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Natriuretic Peptide, Brain; Pulmonary Valve Stenosis; Stroke Volume; Tetralogy of Fallot; Ventricular Function, Right; Ventricular Pressure

Although tetralogy of Fallot (TOF) can be repaired surgically, residual lesions that cause abnormal ventricular load can eventually lead to heart failure. Subclinical biventricular dysfunction in these patients may be detected only by using suitably sensitive indexes. The Tei index determined by the pulsed Doppler method enables the measurement of left ventricular (LV) and right ventricular (RV) function. This study was designed to evaluate the biventricular Tei indexes in adults with operated congenital heart disease and to correlate these indexes with cardiopulmonary capacity and neurohormonal activation. Fifty-nine patients with surgically corrected TOF and 52 patients with operated left-to-right-shunt defects were included in the study. Patients with TOF showed significantly greater LV and RV Tei indexes than those with left-to-right-shunt defects (LV Tei index 0.50 +/- 0.09 vs 0.34 +/- 0.05, RV Tei index 0.37 +/- 0.1 vs 0.25 +/- 0.06; p <0.0001). Peak oxygen uptake was significantly reduced in the patients with TOF (25 +/- 6 vs 32 +/- 6 ml x kg(-1) x min(-1), p <0.0001) and was correlated inversely with the LV Tei index (r = -0.61, p <0.0001). N-terminal-pro-brain natriuretic peptide was significantly increased in patients with TOF (150 +/- 141 vs 57 +/- 39 pg/ml, p <0.0001). In conclusion, in asymptomatic or minimally symptomatic patients with TOF, biventricular dysfunction is detected by the Tei index. Further indexes for heart failure in these patients are increased circulating plasma N-terminal-pro-brain natriuretic peptide and impaired peak oxygen uptake. The combined determinations of these 3 variables enable the identification of congenital heart disease with impaired cardiac function before they become clinically symptomatic.

Topics: Adult; Echocardiography, Doppler, Pulsed; Exercise Tolerance; Female; Heart Failure; Heart Ventricles; Humans; Male; Multivariate Analysis; Myocardial Contraction; Natriuretic Peptide, Brain; Oxygen Consumption; Peptide Fragments; Prospective Studies; Pulmonary Valve Insufficiency; Sensitivity and Specificity; Stroke Volume; Tetralogy of Fallot; Ventricular Dysfunction

Cardiac volumetry by magnetic resonance imaging can guide the timing for reoperation in minimally symptomatic or asymptomatic patients with pulmonary insufficiency after corrected tetralogy of Fallot. Pro-brain natriuretic peptide (BNP) is a marker of ventricular dysfunction and wall stress, and levels may complement magnetic resonance imaging in cardiac assessment before and after pulmonary valve replacement.. Between May 2004 and October 2005, 23 consecutive patients with corrected tetralogy, severe pulmonary insufficiency, and right ventricular end-diastolic volume index greater than 150 mL/m2 underwent elective pulmonary valve replacement. Plasma proBNP levels and magnetic resonance imaging were obtained before and 6 months after pulmonary valve replacement.. There was no surgical mortality or morbidity. Preoperative right ventricular end-diastolic volume index correlated with pulmonary insufficiency, and inversely so with left ventricular ejection fraction, reflecting interventricular interaction. Preoperatively (r = -0.47) and 6 months postoperatively (r = -0.54), log BNP was inversely correlated with right ventricular ejection fraction. Mean preoperative proBNP levels, right ventricular end-diastolic volume index, and pulmonary insufficiency significantly (p < 0.0001) diminished 6 months after pulmonary valve replacement (231 versus 114 ng/L, 184 versus 109 mL/m2, and 44% versus 2%, respectively).. Plasma proBNP is elevated in patients with corrected tetralogy, severe pulmonary insufficiency, and right ventricular dilatation, and it significantly diminishes 6 months after pulmonary valve replacement, mirroring magnetic resonance imaging-documented better right ventricular ejection fraction and smaller right ventricular end-diastolic volume index. Pro-brain natriuretic peptide complements magnetic resonance imaging for cardiac assessment in patients requiring pulmonary valve insertion. Future validation of cutoff levels are required to establish proBNP as a useful diagnostic and follow-up tool in patients with chronic pulmonary insufficiency and failing right ventricles.

Topics: Biomarkers; Child, Preschool; Disease Progression; Heart Valve Prosthesis Implantation; Humans; Hypertrophy, Right Ventricular; Infant; Magnetic Resonance Imaging; Natriuretic Peptide, Brain; Peptide Fragments; Postoperative Complications; Prospective Studies; Pulmonary Valve Insufficiency; Reoperation; Stroke Volume; Tetralogy of Fallot; Time Factors

Elevated levels of brain natriuretic peptide (BNP) have been associated with ventricular dysfunction, and exercise tests have been used for assessing cardiac contractile reserve. We examined the relation between BNP and right ventricular (RV) contractile reserve during exercise in patients after repair of tetralogy of Fallot (TOF). A total of 45 patients, 26 of whom underwent repair of TOF at 2 to 3 years of age and 19 age-matched healthy children, were studied. Plasma levels of BNP were measured at baseline and at maximal exercise. Echocardiography combined with tissue Doppler imaging (TDI) was performed at rest and during supine bicycle submaximal exercise. The peak value of the first derivation of RV pressure (peak dP/dt) was measured by the continuous-wave Doppler method. The severity of pulmonary regurgitation (PR) (mild, moderate, or severe) was based on color Doppler findings. Plasma BNP levels were significantly higher in patients with TOF than in controls (44 +/- 34 vs 6 +/- 4 pg/ml, p <0.01). Exercise was associated with increased plasma BNP levels in both groups. A larger increment in BNP was noted in patients with TOF than in normal subjects (15 +/- 12 vs 2 +/- 2 pg/ml, p <0.01). The peak systolic myocardial velocity (Sa) and peak dP/dt values increased significantly in both groups during exercise; however, the magnitude of increase in both of these values was significantly less in patients with TOF than in controls (36 +/- 19% vs 70 +/- 19% and 42 +/- 11% vs 81 +/- 12%, respectively; p <0.01). There were significant correlations between the increment in BNP and changes in Sa and peak dP/dt values (r = -0.67 and -0.53, p <0.01, respectively), and the severity of PR (r = 0.74, p <0.01). Thus, exercise increases plasma levels of BNP, and greater increases are associated with impaired RV contractile reserve in patients with TOF with various degrees of PR.

Topics: Child; Echocardiography; Exercise Test; Humans; Myocardial Contraction; Natriuretic Peptide, Brain; Observer Variation; Radioimmunoassay; Tetralogy of Fallot; Ventricular Function, Right

Chronic heart failure is associated with neurohormonal activation that is not only related to outcome but is also a therapeutic target. We have attempted to demonstrate whether a similar pattern of neurohormonal activation exists in adult congenital heart disease (ACHD) and, if so, whether it relates to disease severity determined by cardiopulmonary exercise testing.. Concentrations of N-terminal pro-atrial natriuretic peptide, N-terminal pro-brain natriuretic peptide (NT-proBNP), endothelin (ET)-1, renin, aldosterone, adrenalin, and noradrenalin were determined in 50 adults (mean age, 27.8 +/- 1.7 years [+/- SEM]; 26 women) with tetralogy of Fallot (TOF) after surgical repair (New York Heart Association functional class 1.1 +/- 0.1). One hundred age- and sex-matched healthy blood donors served as a control group for NT-proBNP determination. Dimensions of ventricles, left ventricular pump function, and estimated right ventricular (RV) systolic pressure were determined by echocardiography. Maximum oxygen uptake (V(O2max) was measured in all patients using spiroergometry. TOF patients had elevated levels of NT-proBNP compared with healthy individuals: NT-proBNP (women: 180 pg/mL vs 43 pg/mL, and men: 147 pg/mL vs 32 pg/mL; p < 0.0001) and ET-1 (2.5 fmol/L vs 0.7 fmol/L). There was a significant correlation of NT-proBNP to dimension and estimated peak systolic pressure of the RV as well as impairment of V(O2max).. RV dysfunction detected by echocardiography and plasma NT-proBNP determination in asymptomatic or minimally symptomatic TOF patients correlates well with their cardiopulmonary exercise capacity. Thus, these simple and noninvasive screening methods can be used additionally to stratify ACHD patients with impaired cardiac function before they become clinically symptomatic.

Topics: Adult; Biomarkers; Echocardiography; Exercise Test; Female; Humans; Male; Natriuretic Peptide, Brain; Peptide Fragments; Reference Values; Tetralogy of Fallot; Ventricular Function, Right

Topics: Adult; Cardiotonic Agents; Dobutamine; Female; Humans; Hypertension, Pulmonary; Image Processing, Computer-Assisted; Magnetic Resonance Imaging; Male; Natriuretic Peptide, Brain; Pulmonary Valve Insufficiency; Pulmonary Valve Stenosis; Stroke Volume; Tetralogy of Fallot; Ventricular Function, Right; Ventricular Pressure