Hirofumi Saiki1, Seiko Kuwata1, Clara Kurishima1, Satoshi Masutani1, Hideaki Senzaki2. 1. Department of Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan. 2. Department of Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan. Electronic address: hsenzaki@saitama-med.ac.jp.
Abstract
BACKGROUND: We hypothesized that the myocardial oxygen supply-demand balance is impaired in patients after a Norwood procedure and that an abnormal oxygen supply-demand balance is associated with pronounced activation of the renin-angiotensin-aldosterone system and worse clinical outcome after this procedure. METHODS: To investigate the myocardial oxygen supply-demand balance, the subendocardial viability ratio (SEVR) was measured in 29 hypoplastic left heart syndrome patients after the Norwood procedure, in 27 patients with pulmonary atresia whose pulmonary blood flow was supplied from the aortopulmonary (AP) shunt, and in 30 control patients who were considered to have normal biventricular circulation. The SEVR in Norwood (0.57 ± 0.18) and AP shunt (0.66 ± 0.10) patients was significantly reduced compared with that in controls (0.94 ± 0.25, p < 0.001 vs Norwood and AP shunt). RESULTS: After controlling for heart rate, the SEVR was significantly lower in Norwood than in AP shunt patients (p < 0.001). Importantly, the SEVR was significantly lower in Norwood patients with poor clinical outcomes (cardiac arrest before second-stage operation, progressive tricuspid regurgitation, or reduction of ejection fraction <0.35) than in the remaining Norwood patients (0.51 ± 0.12 vs 0.69 ± 0.22, p < 0.01). An SEVR of less than 0.52 had a more than 76% probability of having a poor outcome (p < 0.05). Furthermore, a lower SEVR was significantly correlated with more pronounced renin-angiotensin-aldosterone system activation and elevated natriuretic peptides in serum. Multiple regression analysis revealed that increased aortic stiffness and a smaller neoaorta relative to the native descending aorta were independent determinants of reduced SEVR. CONCLUSIONS: Myocardial oxygen supply-demand imbalance is intrinsic to Norwood circulation but may be improved by technical refinement of aortic reconstruction or afterload-reducing medication with renin-angiotensin-aldosterone system blockade.
BACKGROUND: We hypothesized that the myocardial oxygen supply-demand balance is impaired in patients after a Norwood procedure and that an abnormal oxygen supply-demand balance is associated with pronounced activation of the renin-angiotensin-aldosterone system and worse clinical outcome after this procedure. METHODS: To investigate the myocardial oxygen supply-demand balance, the subendocardial viability ratio (SEVR) was measured in 29 hypoplastic left heart syndromepatients after the Norwood procedure, in 27 patients with pulmonary atresia whose pulmonary blood flow was supplied from the aortopulmonary (AP) shunt, and in 30 control patients who were considered to have normal biventricular circulation. The SEVR in Norwood (0.57 ± 0.18) and AP shunt (0.66 ± 0.10) patients was significantly reduced compared with that in controls (0.94 ± 0.25, p < 0.001 vs Norwood and AP shunt). RESULTS: After controlling for heart rate, the SEVR was significantly lower in Norwood than in AP shunt patients (p < 0.001). Importantly, the SEVR was significantly lower in Norwood patients with poor clinical outcomes (cardiac arrest before second-stage operation, progressive tricuspid regurgitation, or reduction of ejection fraction <0.35) than in the remaining Norwood patients (0.51 ± 0.12 vs 0.69 ± 0.22, p < 0.01). An SEVR of less than 0.52 had a more than 76% probability of having a poor outcome (p < 0.05). Furthermore, a lower SEVR was significantly correlated with more pronounced renin-angiotensin-aldosterone system activation and elevated natriuretic peptides in serum. Multiple regression analysis revealed that increased aortic stiffness and a smaller neoaorta relative to the native descending aorta were independent determinants of reduced SEVR. CONCLUSIONS: Myocardial oxygen supply-demand imbalance is intrinsic to Norwood circulation but may be improved by technical refinement of aortic reconstruction or afterload-reducing medication with renin-angiotensin-aldosterone system blockade.
Authors: Alexandra Traister; Rachana Patel; Anita Huang; Sarvatit Patel; Julia Plakhotnik; Jae Eun Lee; Maria Gonzalez Medina; Chris Welsh; Prutha Ruparel; Libo Zhang; Mark Friedberg; Jason Maynes; John Coles Journal: PLoS One Date: 2018-07-25 Impact factor: 3.240