A Study in Ventricular–Ventricular Interaction: Single Right Ventricles Compared With Systemic Right Ventricles in a Dual-Chamber Circulation

Abstract

Background Ventricular–ventricular interaction is known to occur in the normal human heart. To determine whether it plays a role in the function of single right ventricles, systemic right ventricles were compared with and without a left ventricle mechanically coupled to it. Methods and Results A noninvasive magnetic resonance tagging technique (spatial modulation of magnetization [SPAMM]) that lays intersecting stripes down on the myocardium was used to examine 18 patients with systemic right ventricles: 7 with a single right ventricle who have undergone the Fontan procedure (age, 38.8±8.9 months) and 11 with transposition of the great arteries who have undergone an atrial inversion operation (age, 16.3±3.9 years). The motion of the intersection points was tracked through systole to determine regional twist and radial shortening. Shortening rates also were evaluated. Finite strain analysis was applied to the grid lines using Delaunay triangulation, and the two-dimensional strain tensor and principal E1 strains were derived for the various anatomic regions. Basal and apical short-axis planes through the ventricular wall were categorized into four distinct regions spaced equally around the circumference of the slice. We observed the following results. (1) Strain was greatest and heterogeneity of strain was least in patients with transposition of the great arteries who were status post atrial inversion operation (six of eight regions). Marked differences were noted in the distribution of strain within a given region, from endocardium to epicardium, and from atrioventricular valve to apical plane between patient subtypes and those with a normal left ventricle. (2) Contrary to the normal subject studied by the use of the same method, for both patient subtypes, there was counterclockwise twist in one region, clockwise twist in the posterior or inferior wall, and a transition zone of no twist at which the two regions of twist met. Normal human adult left ventricles studied in short-axis twist uniformly counterclockwise as viewed from apex to base. (3) Radial inward motion was greatest in the superior wall of both types of systemic right ventricle. The inferior walls of Fontan patients and the posterior (ie, septal) walls of patients with transposition of the great arteries, status post atrial inversion, moved paradoxically in systole. The shortening rate at the atrioventricular valve of patients with transposition of the great arteries, status post atrial inversion, was significantly lower than at the apex or in Fontan patients. Conclusions Marked differences in regional wall motion and strain were demonstrated in systemic right ventricles, depending on whether a left ventricle was present to augment its function. Ventricular–ventricular interaction appears to play an important role in affecting the biomechanics of systemic right ventricles. These observations were markedly different from those in the normal systemic left ventricle. These techniques demonstrate tools with which we can begin to evaluate surgical outcomes using regional myocardial mechanics and may provide a clue to single right ventricle failure.