Download The Cardiac Function In The Patients With Congenital Scoliosis

A retrospective study of echocardiographic cardiac function and structure in adolescents with
congenital scoliosis
LIANG Jin-Qian, SHEN Jian-Xiong, LEE Chia-I, WANG Yi-Peng, ZHANG Jian-Guo, Zhao
Hong, and QIU Gui-Xin
Department of Orthopedics, Peking Union Medical Hospital, Chinese Academy of Medical Sciences & Peking Union
Medical College, Beijing 100730, China.
Correspondence to: Prof. SHEN Jian-xiong, Peking Union Medical Hospital, Chinese Academy of Medical Sciences &
Peking Union Medical College, Beijing 100730,China (Tel: 86-10-65296081.
F ax: 86-10-65296081. Email: [email protected]).
Keywords: congenital scoliosis; echocardiography; cardiac structure; cardiac function
Abstract
Background: Patients with congenital scoliosis often also have intraspinal abnormalities and
other organ defects, and few studies of the effects of congenital scoliosis on cardiac function
and structure have been published.
Methods: A total of 215 adolescent patients with congenital scoliosis (average age: 13.58
years) underwent preoperative echocardiography and were then divided into subgroups
according to apex vertebral rotation, side of convexity, curvature severity in the coronal and
sagittal planes, type of deformity, and sex. Differences between the subgroups were compared
by independent-samples t test or a one-factor analysis of variance.
Results: We observed statistically significant differences between patients with right-sided
scoliosis curvature and those with left-sided scoliosis curvature, respectively, in left
ventricular inner diameter at end-diastole (39.39+4.66mm vs. 41.74+4.90mm), left
ventricular inner diameter at end-systole (24.80+3.45mm vs. 25.92+3.07mm),
interventricular septum thickness at end-diastole ( 5.66+0.98mm vs. 5.98+1.03mm), and
posterior wall of left ventricle at end-diastole (5.61+0.98mm vs. 6.06+1.20mm). When the
patients were evaluated by coronal plane Cobb angle (<40º, group 1; 40º-80º, group 2; >80º,
group 3), significant differences were found between groups 2 and 3, respectively, in left
ventricular inner diameter at end-diastole (40.97+5.06mm vs. 38.98+4.45mm) and left
ventricular inner diameter at end-systole (25.53+3.39mm vs. 24.36+3.14mm). When the
patients were evaluated by sagittal plane Cobb angle (<20º, group 1; 20º-40º, group 2; >40º,
2
group 3), significant differences were found in right ventricular dimension between groups 1
and 2 (18.27+3.66mm vs. 16.54+3.57mm) and in diameter of aortic root between groups 2
and 3 (23.83+3.39mm vs. 24.90+3.30mm), respectively. No significant differences were
found in ejection fraction and fractional shortening between patients according to apex
vertebral rotation, side of convexity, coronal plane and sagittal plane Cobb angles, type of
deformity, or sex.
Conclusions: Congenital scoliosis influences cardiac structure, but not function.
3
INTRODUCTION
Congenital scoliosis, or kyphoscoliosis, is an uncommon deformity in which
developmental vertebral anomalies cause segmental abnormal lateral convex angulation of
the spine. These vertebral anomalies, which appear at birth, result in localized impairment of
anterior longitudinal spinal growth in the sagittal plane and increasing deformity as the child
grows to skeletal maturity.1, 2 In some patients, an asymmetrical impairment of anterior spinal
growth result in kyphoscoliosis; however, most of the patients in the present study had
scoliosis.
Clinicians and pathologists in the early 19th century observed that anatomical enlargement
of the heart was often associated with spinal deformity.3, 4 This observation was confirmed
through several series of necropsies during the last century. Latham suggested that secondary
displacement of the heart due to thoracic spine curvature may lead to the development of
cardiac murmurs and extra cardiac sounds.5
Electrocardiography was first systematically included into scoliosis diagnostics by Adorno
and White.6 They observed right axis deviation in 17% of young patients with asymptomatic
scoliosis. Towers and Zorab, in a study of 168 young patients with scoliosis, found common
right and left axis deviation relative to normal readings as well as V2-V4 high-voltage QRS
complexes.7 Results suggest that cardiac function and structure may be affected by scoliosis,
especially congenital scoliosis. However, few studies of the effect of congenital scoliosis on
cardiac function and structure have been published. Furthermore, correlative studies regarding
apex vertebral rotation (AVR), side of curvature, or curvature severity in the coronal and
4
sagittal planes have not been conducted in a large patient population.
The purpose of the present study was to assess the possible effects of AVR, side of
convexity, severity of curvature in the coronal and sagittal planes, types of deformity, and sex
on cardiac structure and function in adolescents with congenital scoliosis. We hoped to obtain
some information pertinent to counseling adolescents with scoliosis.
MATERIALS AND METHODS
Clinical data
The medical records of 215 adolescent patients with congenital thoracic spine scoliosis
followed and/or operated on at Peking Union Medical Collage Hospital from January 2003 to
July 2007 were identified from a single institutional database. The patient study group
consisted of 87 male and 128 female patients aged 10-19 years (mean  SD age: 13.58+2.43
years). Within the 215 patients, deformities included 61 segmentation failures, 86 formation
failures, and 68 mixed-type failures. All diagnoses were confirmed through complete sets of
spine X-ray film, three-dimensional reconstruction, and surgery.
The indications for surgical treatment included a poor prognosis if left untreated and
severity of spinal deformity upon initial consult.8 Patients with scoliosis associated with
congenital heart disease, myelomeningocele, Marfan’s syndrome, neurofibromatosis, skeletal
dysplasia, infection, trauma, or other secondary causes of scoliosis were excluded from the
study.
5
Echocardiographic measurement
M-mode and two-dimensional echocardiography and Doppler ultrasound of all patients
were performed by the same sonographer with a GE Vivid7 scanner (GE Medical Systems,
Horten, Norway) equipped with a 3.4-MHz phased array transducer. Recordings and
measurements were made following international guidelines.9, 10 The parameters evaluated
included the following: interventricular septum thickness at end-diastole (IVSd), posterior
wall of left ventricle at end-diastole (LVPWd), left ventricular inner diameter at end-diastole
(LVIDd), left ventricular inner diameter at end-systole (LVIDs), left atrial dimension (LAD),
right ventricular dimension (RVD), diameter of aortic root (DAR), diameter of the arteria
pulmonalis (DAP), ejection fraction (EF), and fractional shortening (FS).
Radiographic measurements
Preoperative anteroposterior and lateral standing 36-inch-cassette spine radiographs were
obtained in conformed unification at our institution. Radiographic measurements were
manually obtained by two surgeons using a double-blind method, and the mean value was
used. Specifically, scoliosis and kyphosis were measured by using the Cobb method,11 and
the degree of AVR (from I to IV) was measured by using the Nash-Moe method.12
Research methods
Patients with no cardiac or pulmonary disease were divided into subgroups according to
the following parameters:
6
1. AVR: Patients were classified into two subgroups (AVR≤Iº and AVR>Iº).
2. Side of curvature: Patients with simple thoracic or double thoraco-lumbar curves were
further divided into two subgroups according to the side of the thoracic curvature.
3. Coronal plane Cobb angle: Patients were divided into three subgroups according to
curvature angle measured by the Cobb method in the coronal plane (<40º, group 1;
40º-80º, group 2; >80º, group 3).
4. Sagittal plane Cobb angle: Patients were classified into three subgroups according to
kyphosis (<20º, group 1; 20º-40º, group 2; >40º, group 3).
5. Types of deformity: Patients were divided into three subgroups according to type of
deformity (group 1, segmentation failure; group 2, formation failure; group 3, mixed-type
failure).
6. Sex: Patients with simple thoracic or double thoraco-lumbar curves were further divided
into two subgroups according to sex.
Statistical methods
Standard statistical analyses were conducted. All data are expressed as mean + standard
deviation. Independent-samples t test or one-factor analysis of variance was used, as
appropriate, to determine differences between subgroups. Data were analyzed by using SPSS
software for Windows (version 14.0; SPSS Inc., Chicago, IL). P values <0.05 were
considered statistically significant.
7
RESULTS
Adolescents with congenital scoliosis were divided into two subgroups: those with an
AVR ≤Iº (group 1; n=74) and those with an AVR >Iº (group 2; n=141). As evident in Figure 3,
RVD was 16.89+3.39mm in group 1 and 16.99+4.07mm in group 2 (P=0.217), LAD was
27.30+4.09mm in group 1 and 27.38+4.15mm in group 2 (P =0.917), LVIDd was
41.00+4.89mm in group 1 and 39.96+4.89mm in group 2 (P =0.145), and LVIDs was
25.64+3.63mm in group 1 and 25.07+3.18mm in group 2 (P =0.231).
Parameters reflecting cardiac function were also comparable in both groups (Figure 3).
EF (67.58+4.95% vs. 68.08+5.45%) and FS (37.19+3.99% vs. 37.83+4.17%) were shorter in
group 2 than in group 1; however, the difference between groups was not significant. All
variables were within the normal ranges of previous data for a healthy population without
heart disease or scoliosis specific to the Chinese population.13
Patients with simple thoracic or double thoraco-lumbar curves were further divided into
two subgroups according to the side of the thoracic curvature: 129 patients had right-sided
thoracic curvature, and 86 patients had left-sided thoracic curvature. The analysis of variance
showed that the mean LVIDd (41.47+4.90mm vs. 39.39+4.66mm; P<0.001), LVIDs
(25.92+3.07mm vs. 24.80+3.45mm; P =0.016), IVSd (5.98+1.03mm vs. 5.66+0.98mm; P
=0.023), and LVPWd (6.06+1.20mm vs. 5.61+0.98mm; P =0.003) values were significantly
greater in the left-sided group than in the right-sided group (Figure 4). RVD, LAD, DAR, and
DAP—parameters reflecting cardiac function—were not significantly different between
groups (Figure 4).
Patients were divided into three subgroups according to the scoliotic Cobb angle: <40º
8
(n=39), 40º-80º (n=120), and >80º (n=56). No significant differences were observed between
groups 1 and 2. Groups 1 and 2 had similar cardiac structure and function parameters: RVD
(16.85+3.27mm vs.17.14+4.03mm; P=0.68), LAD (26.44+4.36mm vs. 27.82+4.03mm;
P=0.07), LVIDs (25.64+3.31mm vs. 25.53+3.39mm; P=0.86), LVIDd (40.31+4.61mm vs.
40.97+5.06mm; P =0.46), IVSd (5.95+1.07mm vs. 5.73+0.99mm; P=0.25), LVPWd
(5.97+1.16mm vs. 5.72+1.09mm; P=0.20), DAR (24.18+3.38mm vs. 24.61+3.51mm;
P=0.49), DAP (18.26+2.30mm vs. 18.29+2.30mm; P=0.93), EF (67.36+4.93% vs.
67.95+5.32%; P=0.54), and FS (37.28+3.92% vs. 37.55+4.32%; P=0.72), respectively.
Likewise, no significant differences in RVD, LAD, LVIDs, LVIDd, IVSd, LVPWd, DAR,
DAP, EF, and FS were observed between groups 1 and 3 (P>0.05). However, significant
differences in LVIDs and LVIDd were found between groups 2 and 3 (P=0.029 and 0.012,
respectively) (Figure 5).
Patients were further classified into three subgroups according to kyphotic Cobb angle: <20º
(n=33), 20º-40º (n=78), and >40º (n=104). Analysis of the data similarly showed
significant differences in RVD between groups 1 and 2 (18.27+3.66mm vs. 16.54+3.57mm;
P=0.031), although the parameters were within normal ranges. Groups 1 and 2 had similar
cardiac structure and function parameters: LAD (27.06+3.28mm vs. 26.88+3.63mm; P=0.84),
LVIDs (25.64+3.33mm vs. 25.29+3.37mm; P=0.62), LVIDd (41.06+4.04mm vs.
40.36+4.81mm; P=0.49), IVSd (5.74+0.78mm vs. 5.71+1.07mm; P=0.88), LVPWd
(5.80+1.02mm vs. 5.82+1.13mm; P=0.94), DAR (24.82+3.16mm vs. 23.83+3.39mm;
P=0.15), DAP (18.73+2.31mm vs. 18.19+2.40mm; P=0.27), EF (68.01+5.77% vs.
67.77+5.25%; P=0.82), and FS (37.48+4.45% vs. 37.55+4.12%; P=0.94), respectively. There
9
was also a significant difference in DAR between groups 2 and 3 (23.83+3.39mm vs.
24.90+3.30mm; P=0.028). No significant differences in RVD, LAD, LVIDs, LVIDd, IVSd,
LVPWd, DAP, EF, and FS were found between groups 2 and 3 (P>0.05) (Figure 6).
Parameters reflecting cardiac structure and function were comparable between
adolescents with different types of congenital scoliosis, specifically segmentation failure
(group 1), formation failure (group 2), and mixed-type failure (group 3). Groups 1, 2, and 3
had similar LAD (26.95+3.39mm, 27.56+4.53mm, and 27.38+4.20mm), LVIDs
(25.31+3.19mm, 25.47+3.55mm, and 24.91+3.22mm), LVIDd (40.44+4.52mm,
40.72+5.41mm, and 39.74+4.49mm), IVSd (5.87+1.02mm, 5.77+1.00mm, and
5.74+1.03mm), LVPWd (5.90+1.10mm, 5.81+1.13mm, and 5.66+1.05mm), DAR
(24.51+3.41mm, 24.74+3.58mm, and 24.18+2.96mm), DAP (18.43+2.07mm, 18.14+2.68mm,
and 18.37+2.02mm), EF (67.54+5.11%, 68.05+5.40%, and 67.83+4.84%), and FS
(37.23+3.86%, 37.59+4.46%, and 37.55+3.75%) values, respectively. However, obvious
differences in RVD were observed between patients with formation failure and those with
mixed-type failure (17.57+4.13mm vs. 15.99+3.11mm; P<0.05) (Figure 7).
Cardiac structure and function were compared between male and female patients. The mean
LVIDd (41.83+5.36mm vs. 39.31+4.25mm; P<0.001), LVIDs (26.08+3.38mm vs.
24.68+3.20mm; P=0.002), IVSd (6.17+1.19mm vs. 5.52+0.77mm; P<0.001), LVPWd
(6.16+1.27mm vs. 5.54+0.88mm; P<0.001), and DAR (25.22+3.76mm VS. 24.01+2.93mm;
P=0.009) values were significantly greater for male than for female patients. RVD, LAD,
DAF, EF, and FS were not significantly different between the two groups (P>0.05) (Figure 8).
10
DISCUSSION
Congenital scoliosis is often associated with intraspinal abnormalities and other organ
defects. The embryonic development of the vertebrae is closely related to that of the spinal
cord and the organs of the mesoderm.14-18 McMaster reported intraspinal abnormalities in
18% of 251 patients who underwent myelography.17 Guerrero et al. found genitourinary
abnormalities in 34% of patients with congenital scoliosis using ultrasound and intravenous
urography.19 The exact incidence of congenital heart disease associated with congenital
scoliosis has not been reported. Hensinger et al. found a 14% incidence of congenital heart
disease among patients with Klippel–Feil syndrome.20 In our study, 34 patients (15.8%) had
intraspinal abnormalities that included tethered cord, low conus, Chiari malformation,
diastematomyelia, and syrinx. Only 15 patients (6.98%) had urogenital system deformity. The
difference between the results in our study and previously reported studies can be explained
by selective bias. To assess the effect of isolated congenital scoliosis on the heart and avoid
the inborn abnormality of cardiac structure and function, we selected only patients without
congenital heart disease. Consequently, some patients were then excluded from the sample.
Furthermore, ultrasound alone was used as the screening method, which might not be as
sensitive as the combination of ultrasound and intravenous urography.
The crook and rotation of vertebrae decreases the volume of the thoracic cage and collapses
the prothorax on the convex side, which causes a flat back and protrusion of the prothorax on
the concave side. Soft tissue structure also changes accordingly. All of these changes not only
decrease the volume of the thoracic cavity but also restrict respiratory movement of the ribs,
which thus influences cardiopulmonary function.21 Westate and Moe reported that vital
11
capacity and maximal ventilatory volume in patients with scoliosis were lower than normal and
were significantly correlated with the Cobb angle.22 Pulmonary function becomes worse as the
Cobb angle increases. Theoretically, spinal and thoracic deformities will similarly affect the
heart. Therefore, it is assumed that the more severe the deformity of the spine, the worse the
effect on the heart.
Ultrasound was used routinely preoperatively to evaluate cardiac structure and function, i.e.,
to noninvasively measure structural indices of the heart chambers and large vessels, blood flow
rate, direction of bloodstream, and quality of bloodstream. EF and FS are indicators of the
systolic function of the left ventricle.23 Ultrasound is useful for quantitatively and qualitatively
assessing cardiac structure and function.
We found that parameters related to cardiac structure and function were within normal
ranges in adolescents with congenital scoliosis, which suggests that spinal development has little
influence on cardiac structure and function in this population group. This finding is in contrast
with the finding that spinal development does affect pulmonary function. A possible reason for
the lack of effect of spinal deformity on cardiac structure and function is the anatomical position
and characteristic of the heart: the heart is located in the central area of the thoracic cage and is
not restricted or compressed because of deformities that occur during development. Additionally,
the contraction and dilation of the heart are active movements that are not affected by respiratory
movement.
Jackson et al. found that AVR correlated closely with the degree of scoliosis and had the
highest correlation with pain of all radiographic findings and deformities studied.24 However, we
found that cardiac structure and function were similar between patients with an AVR ≤Iº and
12
those with an AVR >Iº.
In a study of 25 patients with congenital scoliosis, Muirhead and Connor found a significant
correlation between diminished vital capacity and severity of curvature.25 The mean age of the
present study population was 12 years, the mean Cobb angle was 71º degrees (range: 43º to 130º),
and the mean forced vital capacity was 67%. In contrast, Day et al. found normal lung function
in 11 untreated patients with congenital scoliosis with a mean age of 11.6 years, whereas the
mean Cobb angle of curvature was much smaller—34º (range: 16º to 58º).26 In order to
determine the relation between the scoliotic Cobb angle and cardiac structure and function in our
study, the patients were subdivided by the severity of spinal deformity. LVIDs and LVIDd were
significantly lower in the group with severe spinal deformity than in the group with moderate
spinal deformity. This finding indicates that severe scoliosis may affect the development of the
heart, especially that of the left ventricle.
McMaster et al. reported that an increase in the severity of kyphosis was associated with a
significant increase in respiratory impairment.27 Assuming that the deformity in the sagittal
plane may also have an influence on the heart, we found a high RVD in patients with flat
back deformity and dilatation of the DAR in patients with kyphosis. Bergofsky et al., by
demonstrating that the wedge pressure and cardiac output were normal, found that pulmonary
hypertension in kyphoscoliotic patients was primarily due to an increase in pulmonary
vascular resistance.28 They considered this to be the result of compression and kinking of
small vessels in the lungs. Therefore, in our study, changes in the sagittal plane may have
resulted in compression and kinking of small vessels in the lungs and peripheral vasculature,
which in turn increased blood pressure in the pulmonary artery and aorta. Obviously,
13
prophylactic spinal surgery at an early age was beneficial for these patients.
Basu et al. reported that the proportion of congenital heart disease was higher in patients
with congenital kyphosis (33%) and in those with scoliosis caused by mixed defects (37%).29
Similarly, in our research, the incidence of RVD was significantly lower in patients with
mixed-type failures than in patients with formation failures. The difference in cardiac
structure between patients with formation failures and those with mixed-type failures
suggests that complex deformities affect the development of the heart more severely than do
simple deformities.
The regimen used to identify possible candidates for congenital spinal deformity surgery
should routinely include echocardiography. Patients with congenital scoliosis resulting from
mixed bony defects and/or a severe scoliotic Cobb angle or deformity in the sagittal plane
should also undergo routine echocardiography, because the risk of cardiac structure in these
patients is higher than that in the healthy population.
Our research showed no significant difference between the indices related to cardiac
function in adolescents with congenital scoliosis. These indices—including AVR, side of the
thoracic curvature, Cobb angle in the coronal plane, Cobb angle in the sagittal plane, type of
deformity, and sex—have little influence on cardiac function.
Although cardiac structure and function in adolescents with congenital scoliosis were found
to be in the normal range, patients with scoliosis in advanced stages usually have clinical signs
and symptoms of cardiac dysfunction.6, 7, 30 It has been hypothesized that cardiac dysfunction in
patients with scoliosis in advanced stages is caused by chronic hypoxemia, which leads to
pulmonary artery hypertension and decreasing cardiac function.
14
Unfortunately, because our study was retrospective, we were unable to determine
whether structural cardiac changes are caused by geometric changes in the heart. Further
research is needed to identify whether these changes persist after correction of spinal
deformities.
In conclusion, congenital scoliosis affects cardiac structure, but not cardiac function.
The main factors related to cardiac structure abnormalities include convexity, Cobb angle in
the coronal and sagittal planes, type of deformity, and sex. Although our conclusion has
important implications in terms of patient assessment and counseling, supplementary
prospective measurements are required to identify the natural history of scoliosis in the adult
life stage.
15
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19
Figure 1. Preoperative echocardiograph of
Figure 2. Preoperative anteroposterior
an adolescent patient with congenital scoliosis.
80.00
radiograph of the spine.
G roup
1.00
2.00
60.00
40.00
20.00
0.00
DAR
R VD
LAD
LVIDd
LVIDs
IVS d
LVP Wd
DAP
FS
EF
Figure 3. Comparison of parameters related to cardiac structure and function between
20
patients with congenital scoliosis with an apex vertebral rotation (AVR) ≤Iº (group 1) and
those with an AVR >Iº (group 2). No significant differences were observed between groups
(P > 0.05). DAR, diameter of aortic root; RVD, right ventricular dimension; LAD, left atrial
dimension; LVIDd, left ventricular inner diameter at end-diastole; LVIDs, left ventricular
inner diameter at end-systole; IVSd, interventricular septum thickness at end-diastole;
LVPWd, posterior wall of left ventricle at end-diastole; DAP, diameter of the arteria
pulmonalis; FS, fractional shortening; EF, ejection fraction.
80.00
G roup
R
L
60.00
40.00
20.00
0.00
DAR
R VD
LAD
LVIDd
LVIDs
IVS d
LVP Wd
DAP
FS
EF
21
Figure 4. Comparison of parameters related to cardiac structure and function between
patients with congenital scoliosis with right-sided (R) or left-sided (L) thoracic curvature.
Left ventricular inner diameter at end-diastole (LVIDd), left ventricular inner diameter at
end-systole (LVIDs), interventricular septum thickness at end-diastole (IVSd), and posterior
wall of left ventricle at end-diastole (LVPWd) values were significantly greater in the
left-sided group than in the right-sided group (P<0.05). DAR, diameter of aortic root; RVD,
right ventricular dimension; LAD, left atrial dimension; DAP, diameter of the arteria
pulmonalis; FS, fractional shortening; EF, ejection fraction.
Figure 5. Comparison of parameters related to cardiac structure and function between
patients with congenital scoliosis with different scoliotic Cobb angles: <40º (group 1),
22
40º-80º (group 2), and >80º (group 3). Significant differences in left ventricular inner
diameter at end-systole (LVIDs) and left ventricular inner diameter at end-diastole (LVIDd)
were found between groups 2 and 3 (P<0.05). DAR, diameter of aortic root; RVD, right
ventricular dimension; LAD, left atrial dimension; IVSd, interventricular septum thickness at
end-diastole; LVPWd, posterior wall of left ventricle at end-diastole; DAP, diameter of the
arteria pulmonalis; FS, fractional shortening; EF, ejection fraction.
Figure 6. Comparison of parameters related to cardiac structure and function between
patients with different kyphotic Cobb angles: <20º (group 1), 20º-40º (group 2), and >40º
(group 3). Significant differences in right ventricular dimension (RVD) were found between
23
groups 1 and 2 and in diameter of aortic root (DAR) between groups 2 and 3 (P<0.05). LAD,
left atrial dimension; LVIDd, left ventricular inner diameter at end-diastole; LVIDs, left
ventricular inner diameter at end-systole; IVSd, interventricular septum thickness at
end-diastole; LVPWd, posterior wall of left ventricle at end-diastole; DAP, diameter of the
arteria pulmonalis; FS, fractional shortening; EF, ejection fraction.
7. Figure 7. Comparison of parameters related to cardiac structure and function between
patients with patients with different types of congenital scoliosis: segmentation failure
(group 1), formation failure (group 2), and mixed-type failure (group 3). Significant
differences in right ventricular dimension (RVD) were observed between patients with
formation failure and those with mixed-type failure (P<0.05). DAR, diameter of aortic
24
root; LAD, left atrial dimension; LVIDd, left ventricular inner diameter at end-diastole;
LVIDs, left ventricular inner diameter at end-systole; IVSd, interventricular septum
thickness at end-diastole; LVPWd, posterior wall of left ventricle at end-diastole; DAP,
diameter of the arteria pulmonalis; FS, fractional shortening; EF, ejection fraction.
.
8 0 .0 0
G ro u p
Ma le
F e m a le
6 0 .0 0
4 0 .0 0
2 0 .0 0
0 .0 0
DAR
R VD
LAD
LVIDd
LVIDs
IVS d
LVP Wd
DAP
FS
EF
Figure 8. Comparison of parameters related to cardiac structure and function between male
and female patients. LVIDd, LVIDs, IVSd, LVPWd and DAR values were significantly
greater for male than for female patients (P<0.05). DAR, diameter of aortic root; RVD, right
ventricular dimension; LAD, left atrial dimension; LVIDd, left ventricular inner diameter at
25
end-diastole; LVIDs, left ventricular inner diameter at end-systole; IVSd, interventricular
septum thickness at end-diastole; LVPWd, posterior wall of left ventricle at end-diastole;
DAP, diameter of the arteria pulmonalis; FS, fractional shortening; EF, ejection fraction.
26