Background
Patients with repaired tetralogy of Fallot often present residual hemodynamic abnormalities leading to right ventricular (RV) burden. Semisupine exercise echocardiography (Ex-Echo) is a validated method for diagnosis and prognosis in ischemic and valvular heart diseases and has potential for the evaluation of RV burden, pressure, and function. The aims of this study were to assess the effect of exercise on the right ventricle in adults with repaired tetralogy of Fallot and to identify factors associated with decreased RV function at peak exercise in an observational study.
Methods
A total of 128 patients with repaired tetralogy of Fallot referred to an outpatient congenital heart disease unit were evaluated by Ex-Echo and conventional clinical and diagnostic examinations (i.e., electrocardiography, transthoracic echocardiography, cardiovascular magnetic resonance, cardiopulmonary exercise testing, and N-terminal pro–brain natriuretic peptide assay). The following Ex-Echo parameters were measured at rest and at peak exercise: tricuspid annular plane systolic excursion, RV pressure, and RV fractional area change (FAC).
Results
Interpretable images for RV FAC analysis were obtained in 123 of 128 patients. In 91 of 128 with detectable tricuspid valve regurgitation, RV systolic pressure during exercise was evaluated. According to positive or negative RV FAC variation during exercise, 74 patients were respectively defined as “responders” on stress echocardiography and 49 as “nonresponders”; the median percentage change between rest and stress was 13.8% (interquartile range, 5.9% to 26.9%) in responders and −13.5% (interquartile range, −25.4% to −7.4%) in nonresponders. Systolic RV systolic pressure increased in a similar manner in the two groups (65 ± 36% in responders vs 59 ± 39% in nonresponders, P = .45). Tricuspid annular plane systolic excursion increased significantly during peak exercise in responders from 17.2 ± 3.4 mm at rest to 19.7 ± 4.3 mm ( P < .0001) but did not in nonresponders (from 16.9 ± 4.7 to 18.1 ± 4.6 mm, P = .20). Left ventricular end-diastolic volume at rest and left ventricular ejection fraction < 50% were related to the lack of increased RV FAC on exercise.
Conclusions
Ex-Echo is feasible in patients with repaired tetralogy of Fallot and allows the integrated assessment of variation in RV systolic pressure, area, and function during exercise, which usefully complement more conventional indices of hemodynamic burden in these patients. Longitudinal follow-up is needed to better delineate the prognostic value of the results of Ex-Echo.
Adult patients with surgically repaired tetralogy of Fallot are an increasing population. In these patients, right ventricular (RV) dilatation and dysfunction induced by RV surgical remodeling, such as infundibulectomy and patch insertion, and/or residual hemodynamic abnormalities, such as pulmonary regurgitation and pathway stenosis of the main pulmonary artery and/or pulmonary branches, are a diagnostic and therapeutic challenge. The onset of RV dysfunction is related to a high incidence rate of morbidity and mortality in this subset. Therefore, early detection of RV dysfunction before it reaches an irreversible stage is of paramount importance for the management of these patients. Rest parameters offer only a partial assessment of RV function, and data during stress are limited. Recently, a few studies have suggested that dobutamine stress assessed by either cardiovascular magnetic resonance (CMR) or transthoracic echocardiography may unmask abnormalities of RV function in patients with repaired tetralogy of Fallot, otherwise unrecognized under resting conditions. Semisupine exercise echocardiography (Ex-Echo) is an established and validated method for both diagnosis and prognosis in patients with known or suspected coronary artery disease and allows the simultaneous assessment of RV global and regional function and Doppler parameters. The aims of this study were to assess the effect of exercise on the right ventricle in adults with repaired tetralogy of Fallot and to identify factors associated with decreased RV function during peak exercise. The study hypothesis was that in patients with repaired tetralogy of Fallot, those who increase RV-FAC during exercise would show a better clinical and imaging profile. Moreover, RV evaluation at peak exercise may help to unmask characteristics not ascertained at rest.
Methods
The initial population consisted of patients with repaired tetralogy of Fallot referred to our outpatient clinic from February 2006 to August 2013 for routine follow-up. This is a tertiary referral center at which patients with operated tetralogy of Fallot are evaluated and followed, recruiting patients from all over Italy. Therefore, consecutive patients operated for tetralogy of Fallot or Fallot-like pathology (double-outlet right ventricle Fallot type, tetralogy of Fallot with pulmonary atresia) referred to our center for follow-up were enrolled. Exclusion criteria were age < 10 years, height < 140 cm, contraindications to CMR, mental retardation, inability to cycle, and associated major cardiac anomalies (atrioventricular defect, major aortopulmonary collateral vessels, Ebstein anomaly, and pulmonary hypertension; n = 30); five more patients were excluded because of poor acoustic windows. The study consisted of analyzing data from two perspectives to provide greater information in the reported results. A first observational, nonrandomized study, with the aim of analyzing factors associated with decreased RV function at peak exercise, was followed by a prospective study of the enrolled patients aiming to understand how RV fractional area change (FAC), and other variables of interest, could be associated with cardiac events. All patients, in addition to conventional imaging evaluation, underwent Ex-Echo. Therefore all patients underwent rest electrocardiography, transthoracic echocardiography, CMR, cardiopulmonary exercise testing, and Ex-Echo. A blood sample was drawn to assay N-terminal pro–brain natriuretic peptide (NT-proBNP). The study was approved by the institutional review board. All patients gave written informed consent when they underwent stress echocardiography. When patients provided written informed consent, they also authorized physicians to use their clinical data according to Italian law. Exercise stress echocardiographic data were collected and analyzed by stress echocardiographers not involved in patient care.
Exercise Stress Echocardiography
All exercise echocardiographic studies were performed on a bicycle ergometer in the semisupine position. The workload was increased in increments of 25 W every 2 min. A 12-lead electrocardiogram was continuously monitored, and blood pressure was recorded at every step. Echocardiographic images were collected at baseline and at peak exercise using a commercially available echocardiographic machine (Vivid 7 [GE Medical Systems, Milwaukee, WI] or iE33 [Philips Medical Systems, Andover, MA]). The semisupine position allows the acquisition of images at peak stress, while the patient is still cycling. All images were recorded digitally and analyzed offline.
The following parameters were measured at rest and at peak exercise: tricuspid annular plane systolic excursion, RV systolic pressure (RVSP), and RV FAC. Tricuspid annular plane systolic excursion was calculated by M-mode echocardiography as the total displacement of the tricuspid annulus from end-diastole to end-systole. RVSP was calculated from tricuspid regurgitation jet velocity, according to standard definition and as recommended by the European Association of Cardiovascular imaging; the changes in RVSP during exercise was referred to as RVSP change and calculated as [(RVSP during exercise − RVSP at rest)/RVSP at rest] × 100.
RV FAC, considered an index of RV inlet function, was calculated from the apical four-chamber view as [(RV end-diastolic area − RV end-systolic area)/RV end-diastolic area] × 100, as previously described ( Figures 1–4 ). The change in RV FAC between rest and peak exercise stress test was calculated as [(RV FAC at peak exercise − RV FAC at rest)/RV FAC at rest] × 100.
The subset of patients with any increase in RV FAC were considered “responders,” whereas those with no change or with any decrease in RV FAC were considered “nonresponders.”
To evaluate inter- and intraobserver variability, two observers (P.F. and L.A.-A.) independently assessed RV FAC change in a random sample of 10 digitally recorded tracings. One investigator (L.A.-A.) assessed intraobserver variability repeating measurements within a period of 4 weeks on the same tracings and on another sample of 20 digitally recorded tracings. The second round of intraobserver measurements was blinded to the results obtained by the first observation.
To evaluate the results, we also separately considered reoperated patients for RV outflow tract (RVOT) reconstruction (either for conduit replacement in tetralogy of Fallot plus pulmonary atresia or for RVOT reconstruction and valvulation in tetralogy of Fallot) and non-reoperated patients; the latter group was then divided into three different categories according to the main RV burden: group 1, with predominant pulmonary regurgitation at rest (pulmonary regurgitation fraction [PRF] > 25% and RVSP ≤ 50 mm Hg); group 2, with predominant pulmonary stenosis at rest (RVSP > 50 mm Hg); and group 3, with mild pulmonary regurgitation and stenosis at rest (PRF ≤ 25% and RVSP ≤ 50 mm Hg). Reoperated patients for pulmonary valve implantation or for right ventricle–pulmonary artery conduit replacement were compared with non-reoperated patients.
CMR
A CMR Signa/GE CV/i 1.5-T scanner and a surface four- and eight-channel cardiac phased-array coil were used. A comprehensive CMR evaluation was performed according to a previously published examination protocol for repaired tetralogy of Fallot. Both left ventricular (LV) and RV short axes were visualized from the base to the apex, as previously described, using commercially available pulse sequences: electrocardiographically triggered, steady-state free-procession, segmented k-space. A commercially available gradient-echo velocity mapping electrocardiographically triggered sequence (PVC-CMR) was used for blood flow determination and particularly for pulmonary regurgitation assessment, reported as PRF. CMR was completed by a contrast-enhanced (gadopentate dimeglumine 0.2–0.4 mL/kg). Delayed enhanced sequences were also performed, and late gadolinium enhancement score was calculated in 86 patients.
The steady-state free precession and PVC-CMR imaging sequences were elaborated by means of commercially available software (Mass plus and CV Flow, respectively, version 4.0; MR Analytical Software Systems, Leiden, The Netherlands).
Cardiopulmonary Exercise Testing
Cardiopulmonary exercise testing was performed on a bicycle ergometer using a ramp protocol with increments of 10 to 20 W/min to keep exercise duration between 8 and 12 min. Oxygen consumption (V o 2 ), carbon dioxide production, and minute ventilation were measured using a breath-to-breath gas analysis (Vmax; SensorMedics, Yorba Linda, CA). Peak V o 2 (the highest value at end-exercise, as a 20-sec average) and ventilatory efficiency on exercise (slope of the ventilation vs carbon dioxide production relation in its linear part) were determined.
NT-proBNP Measurements
Blood samples were drawn from an antecubital vein after 20 min of supine rest. NT-proBNP was measured by a fully automated electrochemiluminescence “sandwich” immunoassay on an Elecsys 2010 analyzer (Roche Diagnostics GmbH, Mannheim, Germany).
Statistical Analysis
Continuous variables are expressed as mean ± SD or median (interquartile range [IQR]), and categorical variables are expressed as percentages. NT-proBNP was transformed to its natural logarithm to obtain a normal distribution.
Analysis of variance or Kruskal-Wallis tests were used as appropriate for multigroup comparison between groups. For continuous variables, intergroup comparisons were tested using the Bonferroni test. For ordinal variables, if the null hypothesis was not rejected, Bonferroni corrections was used for groups; otherwise, Wilcoxon-Mann-Whitney tests was used for each pair, adjusting the α level by dividing by the number of comparisons being made.
Comparison between categorical variables was performed by χ 2 or Fisher exact tests (if an expected cell count was five or less). Student independent t tests or Wilcoxon tests were used as appropriate to compare continuous and ordinal variable differences between reoperated patients and non-reoperated patients and between responders and nonresponders (see exercise echocardiographic methodology for definition). The correlation between continuous variables was tested with Pearson correlation coefficients ( r ). Univariate logistic regression analysis was used to determine which variables, continuous (age, age at primary repair, follow-up from primary repair, QRS duration, workload, V o 2 /kg/min, minute ventilation/carbon dioxide production slope, NT-proBNP, RVSP, RV end-diastolic and end-systolic volumes, RV ejection fraction [RVEF], RV mass, LV end-diastolic and end-systolic volumes, LV ejection fraction [LVEF], PRF, and late gadolinium enhancement score) and categorical (previous cardiac event, previous surgery, type of primary RVOT repair, type of RVOT at study, previous shunt, New York Heart Association class, tricuspid regurgitation at least moderate, RVEF < 40%, LVEF < 50%, and PRF > 25%), might be correlated with variation in RV FAC during exercise. Multivariate logistic regression analysis was performed, taking into account all variables with P values < .10 in univariate analysis. An additional stepwise selection was made to identify the variables more significantly related to RV FAC, by entering variables one by one.
All statistical tests were evaluated with the use of two-tailed 95% confidence intervals, and tests with P values < .05 were considered significant. All analyses were performed using Stata version 10.2 (StataCorp LP, College Stattion, TX).
Outcome Analysis
Follow-up data were obtained from at least one of four sources: review of the patient’s hospital record, personal communication with the patient’s physician, and review of the patient’s chart, telephone interview with the patient conducted by trained personnel, or patient visits to staff physicians at regular intervals in the outpatient clinic. Events were defined as death for all causes, cardiac death, development or progression of heart failure, and tachyarrhythmias. The development or progression of heart failure was defined as worsening of functional class. Occurrence of tachyarrhythmias (both ventricular and atrial) was evaluated with electrocardiography or ambulatory electrocardiographic monitoring. Atrial arrhythmias were defined as atrial fibrillation or flutter, supraventricular tachycardia consisting of an abrupt salvo of three or more consecutive atrial premature beats at a rate of >100 beats/min, and ventricular arrhythmias were defined as nonsustained ventricular tachycardia (three or more beats) or sustained ventricular tachycardia, defined as arrhythmia lasting >30 sec or of any length of time if associated with hemodynamic compromise. When reoperation was performed, follow-up was censored at the time of surgery. Student independent t tests or Wilcoxon-Mann-Whitney tests were used as appropriate to compare continuous and ordinal variable differences between patients with and without cardiac events. Comparison between categorical variables was performed by χ 2 or Fisher exact tests (if an expected cell count was five or less).
Stress Echocardiographic Variability
Inter- and intraobserver variability of RV FAC exercise changes was evaluated using Cohen κ coefficients, and κ ≥ 0.75 was considered excellent concordance.
Results
One hundred twenty-three patients with repaired tetralogy of Fallot (82 men; mean age, 26.2 ± 11.3 years; range, 10.5–53 years) formed the study group. Demographic and surgical data are summarized in Table 1 .
| Variable | Value |
|---|---|
| TOF | 109 (88.6%) |
| DORV Fallot type | 5 (4.1%) |
| TOF-PA | 9 (7.3%) |
| Gender (male) | 82 (66.7%) |
| Age (y) at study | 26.2 ± 11.3 |
| Previous shunt palliation | 42% |
| Median age at primary repair (y) | 2.0 (0.9–4.6) |
| Type of primary RVOT repair | |
| Infundibular patch/commissurotomy | 36 (29%) |
| TAP | 73 (59.5%) |
| Valved conduit/homograft | 14 (11.5%) |
| Type of RVOT at study | |
| Native pulmonary valve | 26 (21%) |
| TAP | 63 (51%) |
| Prosthetic valve/conduit/homograft | 34 (28%) |
| Duration of follow-up since primary repair (y) | 20.3 (13.1–27.8) |
| Reoperated patients | 28 (23%) |
RV FAC at rest was correlated with RVEF assessed by CMR ( r = 0.34; P < .001). There was no difference between the groups with regard to gender, age, age at time of repair, or duration of follow-up.
In Table 2 , the main clinical and imaging results are summarized according to the aforementioned subgroups. Group 3 (patients without significant hemodynamic burden) showed the greatest increase in RV FAC during exercise, while reoperated patients had the lowest RV FAC response. No differences in RVSP at rest and in RVSP percentage change between rest and peak stress were observed between groups; however, RVSP at peak stress was significantly higher in group 1 (predominant pulmonary regurgitation, P = .002). Moreover, in this latter group, LVEF was negatively correlated with RVSP during exercise ( r = −0.45, P = 0.004).
| Variable | Non-reoperated patients ( n = 95) | Group1: predominant PR ( n = 58) | Group 2: predominant PS ( n = 21) | Group 3: mild PR and PS ( n = 16) | P | Reoperated patients ( n = 28) | P # |
|---|---|---|---|---|---|---|---|
| Gender (male) | 64.2% | 58.6% | 71.4% | 75.0% | .354 | 75.0% | .287 |
| NYHA class II vs I | 13.7% | 13.8% | 9.5% | 13% | .720 | 17.9% | .583 |
| CPET (W) | 119.0 ± 39.0 | 117.9 ± 37.6 | 113.5 ± 41.6 | 130.1 ± 41.8 | .447 | 116.0 ± 39.1 | .727 |
| V o 2 /kg/min (mL/kg/min) | 26.1 ± 7.6 | 26.3 ± 7.7 | 24.8 ± 6.0 | 26.6 ± 9.3 | .712 | 24.0 ± 6.5 | .201 |
| ln NT-pro BNP (ng/dL) | 4.7 ± 1.0 | 4.7 ± 0.9 | 4.8 ± 1,3 | 4.2 ± 1.0 | .201 | 4.7 ± 1.0 | .816 |
| QRS (msec) | 152.9 ± 30.0 | 157.1 ± 31.8 | 148.9 ± 25.7 | 143.4 ± 26.7 | .214 | 156.6 ± 24.6 | .568 |
| TR > 2+ | 20.2% | 15.5% | 20.0% | 37.5% | .153 | 28.6% | .350 |
| RVSP at rest (mm Hg) | 44.1 ± 18.8 | 36.6 ± 7.3 | 73.2 ± 17.1 | 32.6 ± 7.3 | <.0001 ∗ | 67.0 ± 25.7 | <.0001 |
| RVSP at exercise (mm Hg) | 72.6 ± 29.2 | 61.9 ± 16.1 | 110.8 ± 24.3 | 49.8 ± 9.0 | <.0001 † | 100.8 ± 40.2 | <.001 |
| RVEDVi (mL/m 2 ) | 154.0 ± 46.8 | 171.6 ± 47.3 | 126.6 ± 29.6 | 126.2 ± 31.3 | <.0001 ‡ | 124.6 ± 27.0 | .002j |
| RVESVi (mL/m 2 ) | 73.9 ± 28.5 | 83.6 ± 30.4 | 58.7 ± 18.0 | 58.9 ± 15.3 | <.0001 § | 66.4 ± 23.0 | .200 |
| RVEF (%) | 51.9 ± 7.1 | 50.7 ± 7.4 | 54.0 ± 7.2 | 53.4 ± 5.3 | .121 | 48.2 ± 7.5 | .019 |
| RV mass (g/m 2 ) | 40.4 ± 10.0 | 40.5 ± 10.0 | 44.2 ± 8.6 | 34.5 ± 9.5 | .034 || | 42.8 ± 12.1 | .318 |
| RV-FAC change (%) | 4 (−6 to 19) | 3 (−7 to 17) | 1 (−6 to 9) | 22 (−1 to 31) | .242 | −5 (−17 to 14) | .389 |
| TAPSE at rest (mm) | 17.6 ± 3.9 | 17.9 ± 4.1 | 16.8 ± 3.9 | 18.0 ± 2.9 | .564 | 15.3 ± 3.1 | .006 |
| TAPSE at exercise (mm) | 19.7 ± 4.6 | 20.0 ± 4.8 | 18.2 ± 3.6 | 21.1 ± 4.3 | .210 | 17.2 ± 3.7 | .015 |
| LVEDVi (mL/m 2 ) | 84.0 ± 13.8 | 81.9 ± 14.2 | 86.4 ± 14.0 | 88.4 ± 11.3 | .162 | 87.7 ± 18.9 | .254 |
| LVESVi (mL/m 2 ) | 33.5 ± 9.2 | 32.4 ± 9.1 | 35.8 ± 11.1 | 34.6 ± 6.4 | .327 | 36.1 ± 14.5 | .272 |
| LVEF (%) | 60.3 ± 6.6 | 60.5 ± 6.8 | 59.3 ± 7.7 | 61.1 ± 4.2 | .698 | 59.8 ± 7.6 | .769 |
| PRF (%) | 35 (25 to 48) | 45 (36 to 50) | 25 (10 to 30) | 9 (5 to 22) | <.0001 ¶ | 9 (1 to 22) | <.0001 |
| LGE score | 4.9 ± 1.4 | 4.9 ± 1.4 | 5.6 ± 1.3 | 4.3 ± 1.4 | .136 | 5.4 ± 1.7 | .161 |
| Cardiac events ( n ) | 9 | 6 | 0 | 3 | 2 |
∗ Difference between groups 1 and 2 ( P < .001) and between groups 2 and 3 ( P < .001).
† Difference between groups 1 and 2 ( P < .001) and between groups 2 and 3 ( P < .001).
‡ Difference between groups 1 and 2 ( P < .001) and between groups 1 and 3 ( P < .001).
§ Difference between groups 1 and 2 ( P < .001) and between groups 1 and 3 ( P < .001).
|| Difference between groups 2 and 3 ( P < .03).
¶ Difference between groups 1 and 2 ( P < .001), groups 2 and 3 ( P < .01), and groups 1 and 3 ( P < .001).
# Difference between reoperated patients and non-reoperated patients.
Comparison between Responders and Nonresponders
According to predefined criteria, 74 patients were responders on stress echocardiography, and 49 were nonresponders (in Figures 1-4 , two sample cases these groups are reported); the median percentage change of RV FAC between rest and stress was 13.8% (IQR, 5.9% to 26.9%) in responders and −13.5% (IQR, −25.4% to −7.4%) in nonresponders. The rate-pressure product reached during Ex-Echo was not different between the two groups (21,169 ± 8,866 vs 21,439 ± 8,227 mm Hg · beats/min, respectively, P = .89), as well as heart rate response increasing with exercise (97 ± 34% in responders vs 96 ± 38% in nonresponders, P = .80).
Percentage of RVSP increased in both groups (65 ± 36% in responders vs 59 ± 39% in nonresponders, P = .45). Tricuspid annular plane systolic excursion increased significantly in responders, from 17.2 ± 3.4 mm at rest to 19.7 ± 4.3 mm ( P < .0001) at peak exercise, but did not in nonresponders (from 16.9 ± 4.7 to 18.1 ± 4.7 mm, P = .20). In Table 3 , the main clinical, transthoracic echocardiographic, and CMR results are reported according negative or positive RV FAC response (responders vs nonresponders) on Ex-Echo; age at evaluation and at repair was not significantly different in the two groups, as well as RV volumes and RVEF on CMR and functional capacity on cardiopulmonary exercise testing. Meanwhile, LVEF was significantly lower in nonresponders than in responders ( P = .03). Moreover, end-systolic LV volumes were higher in nonresponders than in responders. These results were even more significant when reoperated patients were excluded (see Supplemental Table 3 b). LV end-diastolic volume at rest and LVEF < 50% were related to the lack of RV FAC increase.
| Variable | Total ( n = 123) | Nonresponders ( n = 49) | Responders ( n = 74) | P |
|---|---|---|---|---|
| Previous cardiac event | 12.2% | 18.4% | 8.1% | .090 |
| Gender (male) | 66.7% | 75.5% | 60.8% | .090 |
| Age at study (y) | 26.2 ± 11.3 | 26.0 ± 11.8 | 26.3 ± 11.0 | .860 |
| Previous shunt palliation | 41.8% | 41.7% | 41.9% | .980 |
| Age at primary repair (y) | 2.0 (0.9–4.6) | 1.8 (0.9–4.9) | 2.1 (1.0–4.6) | .610 |
| Type of primary RVOT repair | ||||
| Infundibular patch/commissurotomy | 28.9% | 27.1% | 30.1% | |
| TAP | 59.5% | 54.2% | 63.0% | |
| Valved conduit/homograft | 11.6% | 18.7% | 6.9% | .130 |
| Follow-up from correction (y) | 21.2 (14.5–30.5) | 21.0 (14.5–29.0) | 22.4 (14.5–30.5) | .760 |
| Type of RVOT at study | ||||
| Native pulmonary valve | 21.3% | 19.8% | 25.0% | |
| TAP | 50.8% | 48.8% | 55.6% | |
| Prosthetic valve/conduit/homograft | 27.9% | 31.4% | 50.8% | .400 |
| NYHA class II vs I | 14.6% | 14.3% | 14.9% | .930 |
| CPET (W) | 118.3 ± 38.9 | 121.7 ± 38.8 | 116.3 ± 39.1 | .460 |
| V o 2 /kg/min (mL/kg/min) | 25.6 ± 7.4 | 25.4 ± 7.0 | 25.7 ± 7.7 | .800 |
| VE/V co 2 slope | 27.9 ± 6.9 | 27.1 ± 6.3 | 28.3 ± 7.3 | .380 |
| ln NT-pro-BNP (ng/dL) | 4.7 ± 1.0 | 4.8 ± 1.0 | 4.6 ± 1.0 | .380 |
| QRS (msec) | 153.8 ± 28.8 | 157.6 ± 27.8 | 151.2 ± 29.3 | .230 |
| TR > 2+ | 22.1% | 20.8% | 23.0% | .780 |
| RVP at rest (mm Hg) | 49.0 ± 22.4 | 52.0 ± 23.7 | 46.8 ± 21.3 | .240 |
| RVP at exercise (mm Hg) | 79.4 ± 34.2 | 82.8 ± 36.1 | 76.9 ± 32.7 | .420 |
| RVEDVi (mL/m 2 ) | 147.3 ± 44.7 | 149.3 ± 43.8 | 146.0 ± 45.6 | .690 |
| RVESVi (mL/m 2 ) | 72.2 ± 27.5 | 75.4 ± 30.0 | 70.1 ± 25.7 | .300 |
| RVEF (%) | 51.1 ± 7.4 | 49.6 ± 7.4 | 52.1 ± 7.3 | .070 |
| RVEF < 40% | 8.1% | 14.3% | 4.1% | .090 |
| RV mass (g/m 2 ) | 41.0 ± 10.5 | 42.1 ± 11.5 | 40.2 ± 9.7 | .360 |
| LVEDVi (mL/m 2 ) | 84.8 ± 15.1 | 88.5 ± 16.8 | 82.4 ± 13.5 | .030 |
| LVESVi (mL/m 2 ) | 34.1 ± 10.6 | 37.2 ± 13.1 | 32.1 ± 8.1 | .010 |
| LVEF | 60.2 ± 6.8 | 58.6 ± 7.5 | 61.3 ± 6.2 | .030 |
| LVEF < 50% | 7.3% | 14.6% | 2.7% | .030 |
| PRF (%) | 30 (10–45) | 28 (8–45) | 30 (16–43) | .550 |
| PR > 25% | 60.7% | 57.1% | 63.0% | .520 |
| LGE score | 5.0 ± 1.5 | 5.2 ± 1.6 | 4.9 ± 1.4 | .320 |
| TAPSE at rest (mm) | 17.1 ± 3.9 | 16.9 ± 4.6 | 17.2 ± 3.4 | .734 |
| TAPSE at exercise (mm) | 19.1 ± 4.5 | 18.1 ± 4.7 | 19.7 ± 4.3 | .089 |
| Group 1 (%) | 61.1% | 63.7% | 59.7% | |
| Group 2 (%) | 22.1% | 24.2% | 21.0% | |
| Group 3 (%) | 16.8% | 12.1% | 19.3% | .718 |
| Reoperated patients (%) | 22.8% | 32.7% | 16.2% | .033 |
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