Echocardiographic Z-Score to Predict Pulmonary-Systemic Flow Ratio in Children With Atrial Septal Defect

Q: What are the key findings of this study?

An average right ventricular Z-score (ARV) cut-off of +2.0 accurately predicted a catheter-derived pulmonary-to-systemic flow ratio ≥1.5 with an AUC of 0.85 in children with atrial septal defect.

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Atrial septal defect (n=175). Intervention: Echocardiographic Z-score (ARV) vs. Cardiac catheterization (cQp/Qs). Primary outcome: Prediction of catheter-derived pulmonary-to-systemic flow ratio (cQp/Qs) ≥1.5 (AUC 0.85, 95% CI 0.79-0.92, p=<0.001).

Naofumi F. Sumitomo; Kazuki Kodo; Jun Maeda; Masaru Miura; Hiroyuki Yamagishi

doi:10.1253/circrep.cr-25-0119

August 9, 2025Circulation ReportsOpen Access

Echocardiographic Z-Score to Predict Pulmonary-Systemic Flow Ratio in Children With Atrial Septal Defect

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Key result

Average right ventricular Z-score above +2.0 accurately predicts significant shunt flow in pediatric ASD.

AUC 0.85
95% CI 0.79-0.92
P<0.001
n=175

Figures

Why the study?

The correlation between pulmonary-to-systemic flow ratio and right heart enlargement in children with atrial septal defect remains unclear.

Does the echocardiographic Z-score of the right heart predict the pulmonary-systemic flow ratio (Qp/Qs) in children with atrial septal defect?

Study Design

Type

Observational (n=175)

Multicenter

Yes

Structured PICO

Does the echocardiographic Z-score of the right heart predict the pulmonary-systemic flow ratio (Qp/Qs) in children with atrial septal defect?

P

Population

175 children with isolated atrial septal defect (ASD) who underwent cardiac catheterization, median age 6.8 years, 68 males, in Japan. Excluded: genetic anomalies or other conditions affecting right heart size.

I

Intervention

Echocardiographic Z-scores of the right heart (specifically the average of right ventricular basal, mid-cavity, and longitudinal length Z-scores [ARV])

C

Comparator

Cardiac catheterization (reference standard for measuring pulmonary-to-systemic flow ratio [cQp/Qs])

O

Outcome

Correlation between echocardiographic Z-scores and pulmonary-to-systemic flow ratio (cQp/Qs) on cardiac catheterization, and predictive accuracy for cQp/Qs ≥1.5surrogate

Main Result

Effect estimate: AUC 0.85 (95% CI 0.79-0.92)

p-value: p=<0.001

Limitations

Did not include echocardiographic RV area in the 4-chamber view or RV outflow tract diameters
Did not include patients with moderate pulmonary hypertension
Did not include cardiac magnetic resonance (CMR) data as a reference standard
Did not include patients who did not undergo cardiac catheterization
Most participants were Japanese, limiting generalizability to other ethnicities
Retrospective design with a relatively small number of patients

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Implication

The average echocardiographic Z-score of right ventricular dimensions is a strong non-invasive predictor of significant left-to-right shunting (Qp/Qs ≥1.5) in children with atrial septal defects, aiding in the indication for closure.

Abstract

Background: The correlation between pulmonary-to-systemic flow ratio (Qp/Qs) and right heart enlargement in children with atrial septal defect (ASD) remains unclear. This study aimed to (1) assess echocardiographic Z-scores of the right heart, and (2) determine whether they predict Qp/Qs. Methods and Results: This retrospective study included 175 children (median age 6.8 years; 68 males) with isolated ASD who underwent cardiac catheterization between 2013 and 2020 at 2 centers in Japan. Patients with genetic anomalies or other conditions affecting right heart size were excluded. Echocardiographic parameters were measured, converted to a Z-score, and compared with the catheterization data. In all patients, the Qp/Qs on cardiac catheterization (cQp/Qs) significantly correlated with the Z-scores of the right ventricular end-diastolic diameter of the basal (RVB), mid-cavity (RVM), and longitudinal length (RVL; r=0.54, 0.57, and 0.52, respectively). The average of these 3 parameters (ARV) showed the strongest correlation (r=0.63). Z-scores of the right atrium, tricuspid valve, and pulmonary artery showed weaker correlations. An ARV cut-off of +2.0 best predicted cQp/Qs ≥1.5 (area under the curve 0.85; 95% confidence interval 0.79-0.92; sensitivity 76.8%; specificity 82.4%). Regression-predicted cQp/Qs also significantly correlated with measured cQp/Qs (r=0.63). Conclusions: ARV may be a useful, non-invasive marker for assessing cQp/Qs and determining the indication for closure in children with ASD.

Discussion

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Cite This Study

Sumitomo et al. (2025) conducted an observational in Atrial septal defect (n=175). Echocardiographic Z-score (ARV) vs. Cardiac catheterization (cQp/Qs) was evaluated on Prediction of catheter-derived pulmonary-to-systemic flow ratio (cQp/Qs) ≥1.5 (AUC 0.85, 95% CI 0.79-0.92, p=<0.001). An average right ventricular Z-score (ARV) cut-off of +2.0 accurately predicted a catheter-derived pulmonary-to-systemic flow ratio ≥1.5 with an AUC of 0.85 in children with atrial septal defect.

synapsesocial.com/papers/6a0f42d87b46c501a19bc53f https://doi.org/10.1253/circrep.cr-25-0119

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Echocardiographic Z-Score to Predict Pulmonary-Systemic Flow Ratio in Children With Atrial Septal Defect

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Echocardiographic Z-Score to Predict Pulmonary-Systemic Flow Ratio in Children With Atrial Septal Defect

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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