Impairment of left atrial function in pediatric patients with repaired tetralogy of Fallot: a cardiovascular magnetic resonance imaging study

Abstract

We aimed to assess left atrial (LA) strain before LA dilatation in patients with repaired tetralogy of Fallot (rTOF) compared with healthy controls. We also determined the effects of right atrial (RA) dilatation on LA performance using cardiovascular magnetic resonance-feature tracking (CMR-FT). Forty-nine pediatric patients with rTOF and 36 age- and sex-matched healthy controls were prospectively recruited between June 2017 and August 2019. Balanced steady-state free precession (2D b-SSFP) cine, 2D late gadolinium enhancement (LGE) and phase-contrast (PC) sequences were acquired on 1.5 and 3.0 Tesla scanners. Both ventricular and atrial volumes and ejection fraction were measured. Left ventricular (LV) strain and diastolic strain rates were evaluated between the rTOF patient and control groups. LA reservoir (Ɛs), conduit (Ɛe), and booster strain (Ɛa) were determined at LV end-systole, LV diastasis, and pre-LA systole, respectively. The first derivatives of the respective strains yielded corresponding peak strain rates. Statistical analysis was performed using the t-test and Mann–Whitney test for parametric and non-parametric variables, respectively. Correlations were assessed using Pearson’s correlation coefficient for normally distributed variables and Spearman’s correlation coefficient for non-parametric data. Intra-observer and inter-observer variabilities of LA strain and strain rate measurements were determined from ten randomly selected rTOF patients and ten control subjects. LA strain was significantly lower in patients with rTOF compared with controls (Ɛs, P\u2009<\u20090.001; Ɛe, P\u2009=\u20090.002; Ɛa, P\u2009<\u20090.001). The correlations between LA strain and RA stroke volume indices (SVi) and RA ejection fraction (EF) were moderate (Ɛs and SVi, r\u2009=\u20090.538, P\u2009<\u20090.001; Ɛs and RA EF, r\u2009=\u20090.493, P\u2009<\u20090.001; Ɛe and SVi, r\u2009=\u20090.532, P\u2009<\u20090.001; Ɛe and RA EF, r\u2009=\u20090.466, P\u2009<\u20090.001). LA strain and strain rates had good reproducibility in intra-observer and inter-observer analyses. LA strain and strain rates decreased in pediatric patients with rTOF compared with controls before LA enlargement. A dysfunction in LA performance might precede LV dysfunction in patients with rTOF, even in the early stages after repair.