What are the implications of asymmetric ventricles (ventricular asymmetry)?

From the Guidelines

Asymmetric ventricles in the context of congenital heart disease, particularly single ventricle conditions, require a comprehensive imaging strategy to assess the variable anatomy and physiology, with cardiac magnetic resonance (CMR) being a crucial tool for evaluation and management, as recommended by recent guidelines 1.

Clinical Significance and Diagnosis

The condition of having asymmetric ventricles, especially in the context of single ventricle heart diseases, presents a complex clinical scenario. The variability in anatomy, such as D-loop vs L-loop, right vs left ventricle, or true vs functional single ventricle, complicates the development of a unified imaging approach 1. The clinical significance of asymmetric ventricles in this context depends on the underlying anatomy, the stage of surgical reconstruction, and the presence of symptoms or complications.

Imaging and Management

For patients with single ventricle conditions, CMR is essential for assessing ventricular function, volumes, and the presence of any complications such as systemic to pulmonary collaterals, which can impose a volume load on the single ventricle 1. The use of CMR in pediatric congenital and acquired heart disease is endorsed by the American Heart Association, highlighting its importance in the management of these complex conditions.

Treatment and Follow-Up

Treatment of asymmetric ventricles in the context of single ventricle heart disease typically involves a series of surgical procedures aimed at separating the systemic and pulmonary circulations, culminating in the Fontan procedure. The management strategy is highly individualized, depending on the specific anatomy and physiology of the patient's condition. Regular follow-up with imaging, including CMR, is crucial for monitoring the progression of the disease, the effectiveness of the treatment, and the development of any complications.

Recent Guidelines and Recommendations

Recent guidelines, such as those from the Society for Cardiovascular Magnetic Resonance, European Society of Cardiovascular Imaging, American Society of Echocardiography, Society for Pediatric Radiology, and North American Society for Cardiovascular Imaging, emphasize the role of CMR in the evaluation and management of pediatric congenital and acquired heart disease, including single ventricle conditions 1. These guidelines provide a framework for the use of imaging in the diagnosis, treatment, and follow-up of patients with asymmetric ventricles due to congenital heart disease.

From the Research

Asymmetric Ventricles

• Asymmetric ventricles can be a representation of pathology, and it is essential to evaluate the association of asymmetric lateral ventricle (ALV) with clinical and structural pathologies 2.
• The prevalence of ALV in the study population was 6.1%, and headache was the most common reason for head CT examination, significantly more common in the asymmetry group 2.
• The larger ventricle was more common in the left side than in the right, with 70.0% of cases having the larger ventricle on the left side 2.
• Ventricular asymmetry can occur after ventricular shunting, and contralateral placement of the ventricular catheter via ultrasound-guided perforation of the septum pellucidum may decrease the incidence of postshunting ventricular asymmetry 3.
• The use of a specially designed catheter with two sets of holes, allowing holes to be located in both ventricles, may also decrease the incidence of shunt-related ventricular asymmetry 3.

Clinical Importance

• Asymmetric ventricles can be associated with various clinical manifestations, including headache, transient ischemic attack, focal neurologic findings, vertigo, ataxia, visual and hearing disturbances 2.
• The density of different brain sites was found to be similar on both sides in ALV and control groups, suggesting that ALV may not be associated with significant changes in brain density 2.
• Choroidal cystic or solid neoplasm or periventricular dysplasia was detected in 3.5% of ALV patients, highlighting the importance of further evaluation in cases with severe degree of asymmetry or diffuse ventricular enlargement 2.

Diagnostic and Therapeutic Considerations

• The diagnosis of ventricular dysfunction can be complex, and conventional echocardiography combined with new imaging techniques such as tissue Doppler and tissue tracking can detect early subclinical alteration of ventricular systolic function 4.
• Multiparametric echocardiography evaluation and the use of integrative approaches using echocardiography-parameter combinations can be useful for differentiation between primary and secondary systolic dysfunction 4.
• The combination of beta-blockers and ACE inhibitors can be effective in managing various cardiovascular diseases, including hypertension, arrhythmias, and heart failure 5.