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(Circulation. 1999;100:1540-1547.)
© 1999 American Heart Association, Inc.

Clinical Investigation and Reports

Acute Right Ventricular Restrictive Physiology After Repair of Tetralogy of Fallot

Association With Myocardial Injury and Oxidative Stress

Rajiv R. Chaturvedi, MRCP; Darryl F. Shore, FRCS; Christopher Lincoln, FRCS; Sharon Mumby, BSc; Michael Kemp, MSc, MRCPath; J. Brierly, MRCP; Andrew Petros, MRCP, FFARCSI; John M.G. Gutteridge, PhD, DSc; James Hooper, MD, FRCPath; Andrew N. Redington, FRCP, MD

From the Departments of Paediatric Cardiology (R.R.C., J.B., A.N.R.), Cardiac Surgery (D.F.S., C.L.), Anaesthesia and Intensive Care (S.M., A.P., J.M.G.G.), and Clinical Biochemistry (M.K., J.H.), Royal Brompton Hospital, National Heart and Lung Institute, Imperial College of Science, Technology and Medicine, London, UK.

Correspondence to Andrew N. Redington, Cardiothoracic Unit, Great Ormond Street Hospital, Great Ormond Street, London, W1N 3JH, UK. E-mail reding{at}ibm.net

Background—Acute right ventricular (RV) restrictive physiology after tetralogy of Fallot repair results in low cardiac output and a prolonged stay in the intensive care unit (ICU). However, its mechanism remains uncertain.

Methods and Results—In the first 24 hours after tetralogy of Fallot repair (n=11 patients), serial prospective measurements were performed of cardiac troponin T, indexes of NO production (NO₂^- and NO₃^- combined as NOx), and iron metabolism and antioxidants. RV diastolic function was assessed by transthoracic Doppler echocardiography. Patients who had a long stay in the ICU were characterized by restrictive RV physiology (nonrestrictive group [n=7]: 3.0±0.6 days [mean±SD]; restrictive group [n=4]: 10.7±3.1 days). Troponin T peak concentration and the area under its concentration-time curve (AUC) were higher in the restrictive RV group (peak: restrictive group 17.0±2.8 µg/L, nonrestrictive group 10.4±4.6 µg/L, P<0.03; AUC: restrictive group 268.8±73.6 µg · h^-1 · L^-1, nonrestrictive group 136.2±48.3 µg · h^-1 · L^-1, P<0.03). Plasma NOx/creatinine concentrations were higher in the restrictive group than the nonrestrictive group at 2 hours after bypass (restrictive group 1.3±0.4, nonrestrictive group 0.8±0.2; P=0.04) but were similar by 24 hours. Iron loading peaked 2 to 10 hours after bypass and was more severe in the restrictive group (peak transferrin saturation: restrictive group 83.9±13.0%, nonrestrictive group 58.3±16.2%, P=0.05; minimum total iron-binding capacity: restrictive group 0.59±0.21%, nonrestrictive group 0.76±0.06%, P=0.04; minimum iron-binding antioxidant activity to oxyorganic radicals: restrictive group 9.5±22.4%, nonrestrictive group 50.6±11.4%, P=0.01).

Conclusions—After tetralogy of Fallot repair, acute restrictive RV physiology is associated with greater intraoperative myocardial injury and postoperative oxidative stress with severe iron loading of transferrin.

Key Words: tetralogy of Fallot • ventricles • diastole • free radicals

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