Multicenter study comparing shunt type in the norwood procedure for single-ventricle lesions: three-dimensional echocardiographic analysis

Abstract

Background: The Pediatric Heart Network's Single Ventricle Reconstruction (SVR) trial randomized infants with single right ventricles (RVs) undergoing a Norwood procedure to a modified Blalock-Taussig or RV-to-pulmonary artery shunt. This report compares RV parameters in the 2 groups using 3-dimensional echocardiography.

Methods and results: Three-dimensional echocardiography studies were obtained at 10 of 15 SVR centers. Of the 549 subjects, 314 underwent 3-dimensional echocardiography studies at 1 to 4 time points (pre-Norwood, post-Norwood, pre-stage II, and 14 months) for a total of 757 3-dimensional echocardiography studies. Of these, 565 (75%) were acceptable for analysis. RV volume, mass, mass:volume ratio, ejection fraction, and severity of tricuspid regurgitation did not differ by shunt type. RV volumes and mass did not change after the Norwood, but increased from pre-Norwood to pre-stage II (end-diastolic volume [milliliters]/body surface area [BSA](1.3), end-systolic volume [milliliters]/BSA(1.3), and mass [grams]/BSA(1.3) mean difference [95% confidence interval]=25.0 [8.7-41.3], 19.3 [8.3-30.4], and 17.9 [7.3-28.5], then decreased by 14 months (end-diastolic volume/BSA(1.3), end-systolic volume/BSA(1.3), and mass/BSA(1.3) mean difference [95% confidence interval]=-24.4 [-35.0 to -13.7], -9.8 [-17.9 to -1.7], and -15.3 [-22.0 to -8.6]. Ejection fraction decreased from pre-Norwood to pre-stage II (mean difference [95% confidence interval]=-3.7 [-6.9 to -0.5]), but did not decrease further by 14 months.

Conclusions: We found no statistically significant differences between study groups in 3-dimensional echocardiography measures of RV size and function, or magnitude of tricuspid regurgitation. Volume unloading was seen after stage II, as expected, but ejection fraction did not improve. This study provides insights into the remodeling of the operated univentricular RV in infancy.

Trial registration: ClinicalTrials.gov NCT00115934.

Keywords: echocardiography; heart defects, congenital; pediatrics.

Figures

Figure 1

Summation of disc methodology for measurement of right ventricular diastolic volume in hypoplastic left heart syndrome. A= long-axis view of right ventricle with multiple discs; B= corresponding orthogonal view of right ventricle with multiple discs; C= single cross sectional area from disc as shown in A& B; D= corresponding summation of discs as shown in ABC.

Figure 2

Measurement of vena contracta cross sectional area in patient with severe tricuspid regurgitation in hypoplastic left heart syndrome. A=long axis color flow jet of severe tricuspid regurgitation; B=corresponding orthogonal long-axis view of tricuspid regurgitation color flow jet; C=corresponding cross-sectional view of tricuspid regurgitation color flow jet from A and B; D= three-dimensional display of corresponding tricuspid regurgitation color flow jet.