Fetal Congestive Heart Failure Research Articles

Ultrasound features of placental chorioangioma detected by SMI technology before and after thrombosis of feeding vessels: analysis of a clinical case

Objective: Placental chorioangioma is the most common non-trophoblastic vascular benign tumor of the placenta, with an estimated incidence of 1% of all pregnancies. Most chorioangiomas are small asymptomatic lesions that are found incidentally only postnatally during histologic examination of the placenta. Voluminous chorioangiomas (>4–5 cm), however, are less common and are more often diagnosed prenatally, through ultrasound imaging. Color Doppler demonstrates either a single blood vessel feeding the lesion or substantial vascularity within the mass. Large tumors have been associated with multiple adverse perinatal outcomes, including fetal growth restriction, preterm birth, polyhydramnios, fetal congestive heart failure, fetal anemia, fetal hydrops and intrauterine death. Case(s): A 35-years-old primigravida woman with uncomplicated pregnancy was referred to the Ultrasound Centre of Obstetric and Gynecologic of Sant’Anna Hospital, Turin, due to a suspect placental mass seen during the ultrasound performed at 32 weeks of gestation. In this case, detailed ultrasound scans with grey scale and Doppler examination were performed (using Aplio 550; Canon Medical Systems Europe BV, Zoetermeer, The Netherlands). We also decided to study the vascularization of the mass with SMI (superb microvascular imaging) technology. In particular, with the use of SMI, it was possible to visualize the vascularization of the mass more completely which was conspicuous at first but disappeared after thrombosis of feeding vessels with favorable pregnancy outcome. Conclusion: SMI is a new vascularity imaging method that can visualize vessels that exhibit slow flow rates. It uses a system to reduce artifacts by greatly reducing interference from tissue movement.

World Congress of Perinatal Medicine

SPEAKERS ABSTRACTS The application of super slow review of ultrasound clips to a diagnosis of fetal tachyarrhythmia Name and surname: Jun Yoshimatsu Institution: National Cerebral and Cardiovascular Center Email: yoshimatsu.jun.hp@ncvc.go.jp Objective Fetal arrhythmias occur in 1–2% of all pregnant cases. Premature atrial contraction (PAC), premature ventricular contraction (PVC) which are clinically benign are relatively common and do not require therapy. In contrast supraventricular tachycardias (SVTs), atrial flutter (AFL), ventricular tachycardia which are life-threatening are relatively rare but require treatment. These tachyarrhythmias easily complicate fetal congestive heart failure which can be followed by a fetal death. Thus, prenatal treatment for SVT and AFL is warranted to convert to sinus rhythm. Recently our group demonstrated that protocol-defined transplacental treatment for fetal SVT and AFL was effective and tolerable in 90% of cases. In order to choose the appropriate medication for fetal tachyarrhythmia the accurate diagnosis is important. Because fetal electrocardiography is still not available fetal echocardiography is commonly used for the diagnosis of fetal arrhythmia. The M-mode and Doppler echocardiography may achieve prenatal identification of arrhythmic types. The easier method helps more accurate and precise diagnosis of it. Recent advances of ultrasound examination technology allows a high spatial resolution and high temporal resolution at the same time. The image editing of video clips of four chamber view, which is the most easier image plane, is applicable for the diagnosis of fetal arrhythmias. We conducted the research to innovate the useful video clip editing method including a super slow motion for the precise diagnosis of fetal arrhythmias. Method From our fetal echocardiography database, 55 fetal echocardiography video clips (35 AFL, 20 SVT) were reviewed. Four chamber view clips of each case were selected. Every clips were edited into 10% speed. One examiner inserted the clip maker at the timing of atrial contraction and ventricular contraction. The intervals between ventricular contraction and atrial contraction were measured. Also the number of times of contraction of atrium and ventricle and their relations were recorded. Results Every contractions of each portion (atrium and ventricle) could be detected easily with edited video clips. The differentiation between AFL and SVT could be done completely by counting the number of contractions of atrium and ventricle. Also the V-A intervals and the A-V intervals could be measured in one hundredth seconds. In all cases, the diagnosis is compatible with that had made postnatally. Conclusion The first step of this study was depended on the examiner’s naked eyes helped by editing application. The accuracy of each steps of this study were satisfactory. This is the preliminary step to conduct the deep learning of Artificial Intelligence (AI). The most important point of using AI is setting up what to teach and how to teach. Our study showed the possibility of the application of AI to make a diagnosis of fetal tachyarrhythmia.

Fetal aortic valvuloplasty may rescue fetuses with critical aortic stenosis and hydrops.

Critical aortic stenosis (CAS) with a restrictive interatrial septum may lead to fetal congestive heart failure and hydrops, usually culminating in fetal demise if left untreated. The aim of this study was to assess the effects of fetal aortic valvuloplasty (FAV) on hemodynamics and outcome in these patients. This was a retrospective review of fetuses with CAS and signs of hydrops that underwent FAV in our center between 2000 and 2020. Echocardiograms and patients' charts were analyzed for ventricular and valvular dimensions and for outcome. Hydrops was present at the time of intervention in 15 fetuses with CAS that underwent FAV at our center during the study period. All but one patient had at least one technically successful procedure. There were no procedure-related deaths, but three intrauterine deaths occurred. Twelve subjects were liveborn, of whom two died within 24 h after birth owing to persistent hydrops. Ventricular function improved and hydrops resolved within 3-4 weeks after FAV in 71.4% (10/14) of fetuses with a technically successful intervention. A biventricular outcome was achieved in 50% of the successfully treated patients. Fetuses with CAS and hydrops can be successfully treated with FAV. The procedure has the potential to restore sufficient fetal cardiac output, which may lead to resolution of hydrops. Surviving patients seem to be good candidates for a biventricular outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Review Paper. Transplacental Digoxin Treatment In Prenatal Cardiac Problems In Singleton Pregnancies - Meta Analysis (Based On Literature: 1992–2015)

Abstract Based on fourteen case reports from various centres from 1992-2015 and three original studies in 2006-2011, 122 fetuses were subjected to analysis. In these reports, transplacental digoxin treatment was administered to different cardiac anomalies such as SVT , Ebstein’s anomaly, critical AS , absent pulmonary valve syndrome, complete heart block, in foetuses with aneurysm/diverticulum of LV, in tricuspid atresia or dysplasia, rhabdomyoma, pulmonary atresia, HLHS with fibroelastosis, in TTTS and in extracardiac anomalies such as atriovenous malformation or sacrococcygeal teratoma. There was no statistical difference to suggest (Chi-square test) that digoxin was more efficient to control fetal arrhythmias than fetal congestive heart failure in nonarrhythmic patients. Conclusions: Foetal cardiac insufficiency may appear due to different reasons (in normal heart anatomy or in heart defects, in normal sinus rhythm or due to foetal arrhythmias: tachycardias or severe bradycardia) and may be a cause of intrauterine demise. So far, we do not have strong evidence that digoxin treatment may prevent foetal death or prematurity. More research is needed to ascertain if the prolonging of pregnancy resulted from digoxin treatment or if improvement in foetal circulatory insufficiency was influenced by spontaneous regression of foetal cardiac symptoms.

Transport of digoxin-loaded polymeric nanoparticles across BeWo cells, an in vitro model of human placental trophoblast.

Fetal arrhythmias can lead to fetal congestive heart failure and hydrops fetalis. Digoxin (the first-line treatment) has low transplacental permeability and high risk of maternal side effects. Biodegradable digoxin-loaded PEGylated poly(lactic-co-glycolic acid) nanoparticles may increase digoxin transport across BeWo b30 cell monolayers (an in vitro model of trophoblast in human placenta) by reducing the drug's interaction with P-gp. Results/methodology: The nanoparticles showed high encapsulation efficiency and sustained release over 48 h. Transport studies revealed significantly increased permeability across BeWo cell layers of digoxin-loaded nanoparticles when compared with free digoxin. P-gp inhibition also increased the permeability of digoxin, but not digoxin-loaded nanoparticles. This represents a novel treatment strategy for fetal cardiovascular disease which may improve maternal and fetal outcomes.

Biventricular Badness: Rare Images of Ebstein Anomaly of the Tricuspid Valve in a Patient with Hypoplastic Left Heart Syndrome.

We report a rare case of hypoplastic left heart syndrome coexisting in a patient with Ebstein anomaly of the tricuspid valve, which has previously been described only in pathological studies. A fetal echocardiogram at 27-weeks gestation showed severe aortic stenosis with evolving hypoplastic left heart syndrome, significant endocardial fibroelastosis, a dysplastic tricuspid valve with moderate regurgitation, right atrial and ventricular dilation, and signs of fetal congestive heart failure. Due to inadequate left heart size, the patient was not a candidate for fetal intervention for critical aortic stenosis, and repeat studies showed progression of the lesion through the pregnancy. The infant was delivered at 36-weeks gestation with signs of hydrops, and a postnatal echocardiogram confirmed hypoplastic left heart syndrome as well as severe Ebstein anomaly of the tricuspid valve. The infant did not survive to intervention.

A fetal supraventricular tachycardia which converted from blocked premature atrial contractions

We are reporting a case of fetal supraventricular tachycardia (SVT) which converted from blocked premature atrial contractions (PAC). It has been treated by verapamil in utero. We suggest that fetal PACs are usually benign phenomena which resolve spontaneously, but require some follow-up to exclude the development of SVT. SVT is rare but complicated by fetal congestive heart failure or even fetal death.

Relationship between Cardiofemoral Index and the plasma concentration of brain natriuretic peptide in anemic fetuses associated with Rh alloimmunization

Fetal anemia is a common result of alloimmunization and is an important cause of fetal congestive heart failure resulting in heart dilation. Fetuses suspected of having heart failure present a higher Cardiofemoral Index and an increase in plasma BNP levels, because the cardiac hormonal system is activated by increased heart wall stretch due to increased left ventricular volume and pressure overload. Our group studied 33 pregnant women (22-31 weeks' gestation at the first cordocentesis) referred for intrauterine fetal transfusion due to severe red blood cells isoimmunization. Up to 6 h prior to each cordocentesis, all fetuses were submitted to ultrasonography measurements where the Cardiofemoral Index was calculated. Samples of blood from the umbilical vein were collected for hemoglobin concentration and blood gas measurements. Plasma levels of BNP were determined with the use of plasma that had previously been frozen and thawed once. Plasma BNP was measured by radioimmunoassay. Pearson's correlation test and regression analysis were used to determine the association between the plasma concentration of BNP and the Cardiofemoral Index of the anemic fetuses with RH alloimmunization. Anemia was severe in 17 (50%) fetuses, mild in 9 (26.47%) and in 8 patients (23.53%) the fetuses were not anemic; hemoglobin ranged from 3.10 to 15.70 g/dl. The Cardiofemoral Index ranged from 0.43 to 0.87 and it was altered (>or=0.59) in 23 fetuses. A significant positive correlation was observed between BNP plasma fetal concentration and Cardiofemoral Index (Pearson r=0.61, P<0.0001). These results suggest that fetal plasma concentration of BNP may increase in fetuses with heart dilation leading to a positive association between Cardiofemoral Index and plasma concentration of BNP.

Digoxin for the treatment of fetal congestive heart failure with sinus rhythm assessed by cardiovascular profile score

Objective. To evaluate the effects of digoxin on the progression of congestive heart failure (CHF), and to determine the best predictors of perinatal death in fetuses with sinus rhythm and CHF.Methods. This was a retrospective case series of fetuses with CHF treated with transplacental digoxin, evaluated at baseline (before treatment), weekly during treatment, and prior to death or delivery, using a 10-point cardiovascular profile score (CVPS) consisting of echocardiographic markers of cardiac dysfunction: cardiomegaly, valve insufficiency, hydrops, and abnormal venous and arterial Doppler flow profiles. Composite CVPS and component markers were compared before and after digoxin treatment by nonparametric testing and best predictors of perinatal survival assessed by regression analysis and receiver operating characteristics.Results. The overall mortality of the 28 subjects was 32%. First, last, and CVPS after 1 week of treatment predicted survival (odds ratio 2.34, 95% confidence interval 1.10–4.96) with a CVPS of ≥6 being the best predictor of survival (sensitivity 0.83, specificity 0.75). All fetuses that died had notching of the umbilical venous flow. CVPS increased from baseline during treatment (p = 0.003) in all subjects.Conclusions. The CVPS score is useful in assessing therapeutic effects of digoxin in the fetus with multiple etiologies for CHF. Further studies are needed to test the efficacy of digoxin in specific defects causing CHF.

Polihidramnios secundario a corioangioma placentario

Chorioangioma is the most common tumor of the placenta, occurring in approximately 1% of pregnancies. This entity is a benign vascular tumor composed of fetal vascular elements joined by connective tissue and is usually found in contact with the chorionic plate or surrounding areas. Size is highly variable but chorioangiomas usually have a diameter of less than 4 cm. Larger chorangiomas (5 cm or more) can occur in areas of infarction or thrombosis and are more frequently associated with complications such as polyhydramnios, preterm labor, and fetal congestive heart failure. Diagnosis of chorioangioma is made in the second or third trimester by ultrasound, which shows nodular images in the fetal side of the placenta or the inner placenta. Doppler studies reveal the presence of vascularization inside or on the periphery of the mass, although this finding is not always present. The management of this tumor ranges from close surveillance of the pregnancy to more invasive procedures such as chemosclerosis with absolute alcohol or laser devascularization. We report a case of large chorioangioma with polyhydramnios, diagnosed at 33 weeks of gestation.

Fetal echocardiographic detection of myocardial dysfunction with the cardiovascular profile score

Fetal congestive heart failure severity may be estimated by the Cardiovascular Profile Score (CV Score) which is an arrangement of ultrasound mortality markers scored from 0-10 out of 10. Tei index or Myocardial Performance Index (MPI) (isovolumetric contraction time/ejection time) has been described as an afterload-independent parameter of myocardial function. The question addressed in this study was: Does the MPI correlate with the CV Score?

Poor Long-Term Outcome in a Survivor Presenting with the Twin Reversed Arterial Perfusion Sequence In Utero: A Case Report

The twin reversed arterial perfusion (TRAP) sequence is a very rare complication of multiple gestations and is associated with a high mortality rate, reaching more than 50% in pump twins. The four common complications are preterm labor, polyhydramnios, fetal congestive heart failure, and fetal death of the pump twin in utero. Prenatal diagnosis during early pregnancy is possible using detailed ultrasonographic examination. Therapies, including conservative treatment and invasive procedures, are directed toward achieving optimal maintenance of pump twins based on clinical presentation. Risk factors for pump twin mortality include a high twin-to-twin weight ratio, acardiacus anceps, low umbilical artery pulsatility index, and a rapid growth rate in the acardiac twin. Herein, we present a case of TRAP sequence in a patient who underwent conservative treatment and had a poor neurologic outcome during long-term follow-up. Although the experience is still limited, early diagnosis of TRAP sequence and more aggressive treatment, instead of an expectant approach, might be a better option.

Doppler velocimetry for predicting fetal death in a twin pregnancy

Doppler velocimetry for predicting fetal death in a twin pregnancy

F130The importance of the fetal echocardiography in nonimmunological hydrops fetalis (analysis of the 156 cases)

BackgroundThe aim of the research was to assess the usefulness of fetal echocardiography in nonimmunological hydrops (NIHF).Method156 fetuses with NIHF had echocardiography in 1994–99.ResultsThe most common cause of NIHF were structural abnormalities 99/156 (63%), especially congenital heart defects (CHD) 30/156 (19%). The fetal congestive heart failure was present in approx. 50% cases.ConclusionFetal echocardiography in NIHF allows not only the precise diagnose but also helps to establish a prognosis and qualification for ongoing procedures. Fetal echocardiography should become the recommended procedure in diagnostic/therapeutic algorithm in cases with NIHF.

Color Doppler imaging in the diagnosis and management of chorioangiomas.

Color Doppler imaging was used to investigate nine consecutive cases of placental tumors referred for evaluation to a tertiary referral unit. Gray-scale ultrasound findings were of a chorioangioma which was subsequently confirmed on pathologic examination. On color Doppler imaging (CDI), three tumors appeared avascular and the pregnancies were uncomplicated, two had only a few vessels in their periphery, and four contained numerous vessels. These vascular chorioangiomas were complicated by polyhydramnios and premature labor (n = 3), isolated polyhydramnios (n = 1), fetal growth restriction (n = 1) and generalized non-immune fetal hydrops (NIHF) (n = 1). The maximum diameter of the tumors ranged between 3 and 10 cm. There was no direct association between the size and location of the tumor and the development of complications. Successful amnioreduction was performed in the three cases of polyhydramnios and premature onset of labor. Vascular sclerosis was attempted unsuccessfully in the case complicated by severe NIHF. Our data indicate that the vascularization of the tumor is a pivotal determinant factor of pregnancy outcome. Where the tumor is avascular, no specific complications should be expected. Where the tumor is vascularized, and in particular if it contains numerous large vessels, serial ultrasound and Doppler examinations are warranted to detect polyhydramnios and early features of fetal congestive heart failure.

Prenatal diagnosis of Klippel–Trénaunay–Weber syndrome as a cause forin utero heart failure and severe postnatal sequelae

Ultrasound examination led to prenatal diagnosis of Klippel-Trénaunay-Weber syndrome complicated by early fetal congestive heart failure. The postnatal course was complicated by the Kasabach-Merritt syndrome of thrombocytopenia due to platelet consumption within the haemangioma. There was need for neonatal cardiopulmonary resuscitation and limb amputation.

Perinatal cardiology: Current and future technologies for the diagnosis of fetal congestive heart failure

Perinatal cardiology: Current and future technologies for the diagnosis of fetal congestive heart failure

Tissue Iron Storage Patterns in Fetal Hydrops Associated with Congestive Heart Failure

To learn whether fetal congestive heart failure causes a characteristic tissue iron storage pattern, we selected 15 neonatal autopsy cases of hydrops fetalis in which both the clinical and gross autopsy findings suggested intrauterine congestive heart failure. The latter appeared to be due to functional causes in 10 (3 nonhemolytic anemia, 4 cardiac dysrhythmia, 3 dilated cardiomyopathy) and was associated with cardiac malformation in 5. We graded the amount of hepatocellular siderosis, reticuloendothelial siderosis, and renal tubular siderosis in Perls-stained microscopic sections of liver, spleen, and kidney and compared the iron storage pattern with that in 15 normally developed neonatal autopsy controls (4 preterm, 11 term) and a further 7 with hemolytic anemia (5 alpha-thalassemia, 2 parvovirus B19 infection). Liver cell siderosis was absent in the three cases with nonhemolytic anemia. It was increased in 11 of the remaining 12 cases, as in hemolytic anemia controls. Among the five cardiac malformation cases, three had proximal renal tubular siderosis (as in hemolytic anemia controls) attributed to turbulent blood flow through the heart. Among the five, hydrops appeared to be due to prenatal closure of the foramen ovale in one and to prenatal constriction of the ductus arteriosus in another. In one of the five, and despite complex malformation of the heart, hydrops appeared to be due to complete heart block. We concluded that, although clinical information and morphologic assessment of the heart were basic to identifying a cardiac cause of fetal hydrops, histologic assessment of the pattern of iron storage helped confirm the pathologic diagnosis. Analysis of the pathologic findings led to a scheme for categorizing cardiogenic fetal hydrops.

Association of prenatal closure of the foramen ovale and fetal parvovirus B19 infection in hydrops fetalis

Stenosis of the foramen ovale was found at autopsy in a preterm hydropic female who died 3 hours after birth. Subsequently, fetal infection by the human parvovirus B19 was diagnosed by serology collected at autopsy and by identifying the viral genome in both the placenta and autopsy liver by polymerase chain reaction. Morphologic findings at autopsy suggested that the disease was in a recovery phase. Prenatal closure of the foramen ovale, as an isolated lesion, is a recognized association of fetal hydrops because right-to-left cardiac shunting through the foramen is obligatory during fetal life. Parvovirus infection is also associated with fetal hydrops, the mechanism being congestive heart failure secondary to acute anemia. Coincidence in this case of both a cardiac and an infective cause of fetal hydrops suggests that the two putative causes are related. We suggest that an episode of fetal congestive heart failure (triggered in this case by anemia caused by fetal parvovirus infection) may initiate prenatal closure of a normally formed and previously patent foramen ovale. If this is true, the congenital anatomic anomaly would represent a cardiac deformation acquired during fetal life rather than a malformation dating from embryonic life.

Venous Doppler ultrasonography in the fetus with nonimmune hydrops

Eighteen pregnancies with nonimmune hydrops fetalis were referred for fetal echocardiography to rule out congenital heart disease. In 14 of these cases, pulsating blood velocities were recorded in the umbilical vein, which in a normal population had a nonpulsatile blood velocity pattern. The four cases without pulsations in the umbilical vein were found to have intrauterine viral infections. In the last 10 cases examined, the umbilical venous pulsations were found to reflect abnormal central venous pulsations during atrial systole suggesting increased fetal central venous pressure. Right ventricular shortening fraction was significantly decreased in the group with umbilical venous pulsations compared with those without (0.18 versus 0.32, p less than 0.05). All the fetuses without venous pulsations survived, but only four of the 14 with pulsations survived (p less than 0.05). The results suggest that blood velocity recordings in the umbilical and central veins of the fetus can give valuable clinical information with regard to the presence of fetal congestive heart failure and differentiate between this physiologic state and other causes of nonimmune hydrops fetalis. This may have implications for fetal diagnostic work-up and prognosis.