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Circumferential clues: strain patterns and arrhythmia risk in pulmonary regurgitation
Published online by Cambridge University Press: 10 October 2025
Abstract
Slim et al.’s paper provided an insight into the differences between repaired tetralogy of Fallot and isolated pulmonary regurgitation in their strain. Repaired tetralogy of Fallot had higher right ventricular circumferential strain, while isolated pulmonary regurgitation relied on longitudinal strain more. This allowed the authors to infer that repaired tetralogy of Fallot can withstand more chronic regurgitation before valve replacement is necessary. We highlighted new findings relevant to this paper. Arrhythmia in repaired tetralogy of Fallot is associated with a reduced global circumferential strain of the right ventricle. Specifically, a value of below -14% was associated with a 6.3 times increase in the risk for an arrhythmic event. We believe this would be beneficial for patients when considered for valve replacements, suggesting modification of current valve replacement guidelines to include strain thresholds alongside current volumetric thresholds. However, the data for isolated pulmonary regurgitation remains scarce. Further investigation is needed to provide clearer timelines for valve replacement. We emphasised the importance of exploring the underlying architecture of repaired tetralogy of Fallot patients’ hearts and why they could generate more global circumferential strain. We acknowledged the broader effect of this paper and its specific benefit in our country, Egypt. This paper provided insights useful for broader global health impact, especially in low-income countries.
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References
Slim, G, Pagano, J, Punithakumar, K et al. Comparisons of right ventricular strain between repaired tetralogy of Fallot and isolated pulmonary regurgitation. Cardiol Young 2025; 35:1335–1343.CrossRefGoogle ScholarPubMed
Kangvanskol, W, Chungsomprasong, P, Sanwong, Y et al. Myocardial strain analysis by cardiac magnetic resonance associated with arrhythmias in repaired tetralogy of Fallot patients. BMC Med Imaging 2024; 24: 328.CrossRefGoogle ScholarPubMed
Stout, K, Daniels, C, Aboulhosn, J et al. AHA/ACC guideline for the management of adults with congenital heart disease: a report of the American College of Cardiology/American heart association task force on clinical practice guidelines. J Am Coll Cardiol 2018; 73 :e81–e192.CrossRefGoogle Scholar
Harrild, DM, Powell, AJ, Tran, TX et al. Long-term pulmonary regurgitation following balloon valvuloplasty for pulmonary stenosis risk factors and relationship to exercise capacity and ventricular volume and function. J Am Coll Cardiol 2010; 55 :1041–1047.CrossRefGoogle ScholarPubMed
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We would like to thank Slim et al. Reference Slim, Pagano and Punithakumar1 for this interesting paper. It is well known that tetralogy of Fallot repair can cause pulmonary regurgitation. But there appear to be architectural differences between isolated pulmonary regurgitation and tetralogy of Fallot. This raises the question: when is a valve repair indicated for both conditions?
The authors demonstrate that repaired tetralogy of Fallot patients’ right ventricles had higher circumferential strain. This is due to the unique architecture of the heart of tetralogy of Fallot patients, which is more suited towards withstanding chronic regurgitation, without an increase in size of the right ventricle. This allows valve replacements to be delayed for repaired tetralogy of Fallot patients. However, in isolated pulmonary regurgitation, the architecture is less adaptable, and the ventricle relies more on longitudinal strain. Accordingly, isolated pulmonary regurgitation patients should have valve replacements earlier.
We would like to mention new findings complementary to this paper. It has been recently shown that reduced strain is associated with arrhythmic events, especially at a right ventricle global circumferential strain below -14%, which causes 6.3 times the possibility of arrhythmic events, Reference Kangvanskol, Chungsomprasong and Sanwong2 and so therefore, considering traditional guidelines are focused on volumetric thresholds such as right ventricular end-diastolic volume instead of strain, Reference Stout, Daniels and Aboulhosn3 we believe it would be of benefit to patients to include replacement based on a right ventricle global circumferential strain below -14%.
There remains a large knowledge gap when it comes to isolated pulmonary regurgitation, where most studies only quote pulmonary regurgitation burden and right ventricle dilatation. Reference Harrild, Powell and Tran4 Further research into arrhythmias and strain in isolated pulmonary regurgitation would provide a clearer timeline for valve replacement.
It is also of great interest to further pursue the reasons for the increased adaptability of tetralogy of Fallot patients’ hearts. Factors such as ventriculotomy, septal patching, and right ventricle architecture are contributors to the increased circumferential strain of repaired tetralogy of Fallot patients and would be of benefit to investigate further.
In conclusion, this study is essential in preventing premature valve procedures and understanding the most appropriate time frame for valve replacement. This particularly affects low-income countries, like Egypt, where we are from, by preventing unnecessary spending. We encourage further research in this field, especially for broader global impact.
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This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
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