Fetal Echocardiography Research Articles

Fetal Cardiovascular MRI - A Systemic Review of the Literature: Challenges, New Technical Developments, and Perspectives.

Fetal magnetic resonance imaging (MRI) has become a valuable adjunct to ultrasound in the prenatal diagnosis of congenital pathologies of the central nervous system, thorax, and abdomen. Fetal cardiovascular magnetic resonance (CMR) was limited, mainly by the lack of cardiac gating, and has only recently evolved due to technical developments. A literature search was performed on PubMed, focusing on technical advancements to perform fetal CMR. In total, 20 publications on cardiac gating techniques in the human fetus were analyzed. Fetal MRI is a safe imaging method with no developmental impairments found to be associated with in utero exposure to MRI. Fetal CMR is challenging due to general drawbacks (e. g., fetal motion) and specific limitations such as the difficulty to generate a cardiac gating signal to achieve high spatiotemporal resolution. Promising technical advancements include new methods for fetal cardiac gating, based on novel post-processing approaches and an external hardware device, as well as motion compensation and acceleration techniques. Newly developed direct and indirect gating approaches were successfully applied to achieve high-quality morphologic and functional imaging as well as quantitative assessment of fetal hemodynamics in research settings. In cases when prenatal echocardiography is limited, e. g., by an unfavorable fetal position in utero, or when its results are inconclusive, fetal CMR could potentially serve as a valuable adjunct in the prenatal assessment of congenital cardiovascular malformations. However, sufficient data on the diagnostic performance and clinical benefit of new fetal CMR techniques is still lacking. · New fetal cardiac gating methods allow high-quality fetal CMR.. · Motion compensation and acceleration techniques allow for improvement of image quality.. · Fetal CMR could potentially serve as an adjunct to fetal echocardiography in the future.. · Knapp J, Tavares de Sousa M, Schönnagel BP. Fetal Cardiovascular MRI - A Systemic Review of the Literature: Challenges, New Technical Developments, and Perspectives. Fortschr Röntgenstr 2022; 194: 841 - 851.

The effect of gestational diabetes mellitus on fetal right heart growth in late-term pregnancy: A prospective study.

Gestational diabetes mellitus (GDM) is a complication of pregnancy strongly associated with an increased risk of structural fetal abnormalities. As the fetal heart grows quickly during the late-term pregnancy period, it is important to understand fetal heart growth before birth. This study explored how GDM affects fetal heart growth by evaluating basic echocardiography indicators during late pregnancy. This prospective, longitudinal study included 63 GDM patients (GDM group) and 67 healthy pregnant women (control group). All subjects underwent fetal echocardiography scans at gestational weeks 28-32, 32-36, and 36-40. Twelve echocardiographic indicators were assessed at each observation and analyzed by using a mixed model. The left atrial diameter (LA) and left ventricular end-diastolic diameter (LV) similarly increased from the first to the third observation. The right ventricular end-diastolic diameter (RV) was significantly different between the groups, and a group × time interaction was detected. The tricuspid annular peak systolic velocity (s') increased more rapidly in the GDM than the control group during the first to second observations, and the group × time interaction was significant. The increase in the tricuspid annular plane systolic excursion (TAPSE) of the GDM group was "slow-fast", while that of the control group was "fast-slow", during three observations. After adjusting covariates, the group difference and interaction effect of TAPSE and RV remained significant. The differences in fetal right heart indicators between the GDM and control groups suggest that GDM may affect the structure and functional growth of the fetal right heart during late-term pregnancy.

Prevalence of Congenital Heart Diseases in Neonates of Diabetic Mothers: A Cross Sectional Study in Yazd

Background: Maternal hyperglycemia is a critical risk factor for congenital heart diseases (CHD). Despite advancements in the medical management of diabetic mothers, the CHD in their infants are still more recurring compared to infants of the general population. The primary purpose of this investigation was to explore the prevalence of CHD in infants of diabetic mothers (IDMs). The study was also aimed at investigating possible associations between the types of maternal diabetes with the incidence of CHD in IDMs especially the status of diabetic control.
 Methods: This cross-sectional study was performed between October 2016 and September 2017, in a Heart Center in Yazd. The cases were comprised of 150 neonates of mothers with diabetes. We determined CHD via fetal echocardiography during the first day of childbirth and estimated the prevalence of CHD in IDMs and its association to control status of diabetes in mothers.
 Results: The prevalence of CHD in IDMs was 12.7%. The results showed that there was a significant relationship between maternal uncontrolled diabetes and a high incidence of CHD in IDMs (P ≤ 0.0001), but there was no association between the type of diabetes and the incidence of HCM.
 Conclusion: We concluded that controlling maternal diabetes has the greatest effect on the prevention of CHD in neonates. The prevalence of CHD in IDMs was 12.7% which is high that may be due to poor control of diabetes in pregnant women in Iran. Also, neonates of diabetic mothers need more cardiac evaluation tests and follow-ups. Therefore, more studies on the effects of maternal diabetes-induced CHD in neonates are needed.

Fetal Doppler Echocardiographic Assessment Predicts Severe Postnatal Obstruction in Total Anomalous Pulmonary Venous Connection

Obstructed total anomalous pulmonary venous connection (TAPVC) is a form of critical congenital heart disease that usually requires urgent postnatal intervention. Knowing which patients have severe obstruction can aid delivery planning. The authors previously developed a novel quantitative metric of pulmonary venous flow, the pulmonary venous variability index (PVVI). The aim of this study was to test the hypothesis that fetal PVVI and vertical vein Doppler velocities are associated with severe pulmonary vein obstruction postnatally. A retrospective cohort study of neonates with prenatally diagnosed TAPVC was performed. Patients who underwent fetal echocardiography at the Children's Hospital of Philadelphia with Doppler interrogation of the vertical vein were included for analysis. Twenty-nine patients met criteria (21 with heterotaxy, 18 with supracardiac TAPVC). The latest gestation fetal echocardiogram was used. Severe pulmonary vein obstruction was defined as preoperative death or urgent surgery or catheter-based intervention (first day of life). Measurements of PVVI, defined as (maximum velocity-minimum velocity)/mean velocity, were made offline. Wilcoxon rank sum models were used to assess the associations of severe obstruction and PVVI and maximum, mean, and minimum velocities. The mean gestational age at the latest fetal echocardiographic examination was 35weeks (range, 30-39weeks). Twelve of the 29 patients (41%) met criteria for severe pulmonary vein obstruction. Lower PVVI was associated with greater risk for severe pulmonary venous obstruction (P=.008). The maximum, mean, and minimum velocities in the vertical vein were all significantly associated with severe pulmonary venous obstruction (P=.03, P=.03, and P=.007, respectively). Qualitative assessment of obstruction was not significantly associated with the outcome. Interobserver reliability for all vertical vein Doppler metrics was high (intraclass correlation coefficient > 0.9). Fetal PVVI and maximum, mean, and minimum velocities are associated with severe postnatal pulmonary vein obstruction in TAPVC. Accurate prediction of obstructed TAPVC could allow safer delivery planning. Further research with larger sample sizes is needed to identify the ideal cutoff values for these Doppler measures.

Maximal Reduction of STIC Acquisition Time for Volumetric Assessment of the Fetal Heart-Benefits and Limitations of Semiautomatic Fetal Intelligent Navigation Echocardiography (FINE) Static Mode.

(1) Objective: To scrutinize the reliability and the clinical value of routinely used fetal intelligent navigation echocardiography (FINE) static mode (5DHeartStatic™) for accelerated semiautomatic volumetric assessment of the normal fetal heart. (2) Methods: In this study, a total of 296 second and third trimester fetuses were examined by targeted ultrasound. Spatiotemporal image correlation (STIC) volumes of the fetal heart were acquired for further volumetric assessment. In addition, all fetal hearts were scanned by a fast acquisition time volume (1 s). The volumes were analyzed using the FINE software. The data were investigated regarding the number of properly reconstructed planes and cardiac axis. (3) Results: A total of 257 volumes were included for final analysis. The mean gestational age (GA) was 23.9 weeks (14.3 to 37.7 weeks). In 96.9 (standard acquisition time, FINE standard mode) and 94.2% (fast acquisition time, FINE static mode) at least seven planes were reconstructed properly (p = 0.0961, not significant). Regarding the overall depiction rate, the standard mode was able to reconstruct 96.9% of the planes properly, whereas the static mode showed 95.2% of the planes (p = 0.0098). Moreover, there was no significant difference between the automatic measurement of the cardiac axis (37.95 + 9.14 vs. 38.00 + 8.92 degrees, p = 0.8827, not significant). (4) Conclusions: Based on our results, the FINE static mode technique is a reliable method. It provides similar information of the cardiac anatomy compared to conventional STIC volumes assessed by the FINE method. The FINE static mode has the potential to minimize the influence of motion artifacts during volume acquisition and might therefore be helpful concerning volumetric cardiac assessment in daily routine.

Accuracy of fetal echocardiography diagnosis and anticipated perinatal and early postnatal care in congenital heart disease in mid-gestation.

The aim of this study was to determine discrepancies in fetal congenital heart disease (CHD) diagnoses and anticipated early postnatal care and outcomes. A retrospective review of 462 randomly selected cases (23% of all cases) referred to a fetal cardiac assessment during the second trimester (mean 26 weeks) at the Children's Hospital in Helsinki between October 2010 and December 2020. Discrepancy between prenatal and postnatal CHD case evaluations was assessed with independently provided cardiac severity and surgical complexity scores. In all, 250 cases, 181 CHD and 69 normal, with complete prenatal and postnatal live birth data as well as seven fetal autopsy reports available were included in the analysis. There were 12 false normal and seven false abnormal prenatal assessments. The prenatally anticipated level of early neonatal care was actualized in 62% and prostaglandin infusion in 95%. In total, 32.7% (84/257) cardiac severity scores were discrepant and in 12,4% (32/257) cases the discrepancies were considered significant (≥ +/- 2 scores). Among significant discrepancies, CHD severity score was overestimated in 13 and underestimated in 19 in fetal assessment. Progression of CHD severity after mid-gestation and during early neonatal phase explained eight of 19 underestimated fetal assessments. The most common discrepant diagnostic categories included ventricular septal defects (n=7), borderline ventricles (n=7; 5 left heart, 1 right heart and 1 double outlet right ventricle/transposition of the great arteries), arch anomalies including coarctations (n=5) and tricuspid valve dysplasias (n=4) with a significant change in postnatal diagnoses and treatment. Although fetal CHD diagnosis and counseling is accurate and reliable in general, the study elaborates specific areas of uncertainty in clinical fetal cardiology practice that may be important to consider in fetal CHD evaluation and counseling provided in mid-gestation.

Improvement of diagnostic efficiency in fetal congenital heart disease using fetal intelligent navigation echocardiography by less-experienced operators.

This study investigated the feasibility and accuracy of fetal intelligent navigation echocardiography (FINE) for the prenatal diagnosis of congenital heart disease (CHD) by inexperienced and experienced operators. In this prospective study, all volume data sets from 120 fetuses with a broad spectrum of CHD were acquired using spatiotemporal image correlation technology. The prenatal diagnostic procedures were performed by two operators with different experience (beginner: 1year and expert: 15 years) using FINE and traditional fetal echocardiography. Data were analyzed on the time of examination and acquisition of results. Diagnoses made by FINE and traditional echocardiography were completely consistent with the final diagnosis of CHD in 98 (81.66%) versus 20 (16.66%) (P< 0.001) beginners and 87.50% (n= 105) versus 101 (84.16%) experts, respectively. On the contrary, there was significant difference using traditional echocardiography (16.66% versus 84.16%, P< 0.001) by two examiners. Furthermore, the examination time decreased when using FINE compared with using traditional echocardiography (beginner operators: 4.54 ± 1.03 min versus 20.58 ± 3.36 min, P< 0.001; expert operators: 3.89 ± 0.96 min versus 12.73 ± 1.62 min, P< 0.001). Based on our results, a prenatal diagnosis of CHD can be made with high feasibility and accuracy using FINE compared with traditional fetal echocardiography for beginner operators.

Fetal Echocardiographic Predictors of Postnatal Surgical Strategies in Critical Pulmonary Stenosis or Atresia with Intact Ventricular Septum: A Meta-Analysis

Background: Critical pulmonary stenosis or atresia with intact ventricular septum (PSAIVS) may be managed either by biventricular repair or univentricular palliation. This systematic review and meta-analysis aimed to synthesize the evidence for the role of fetal echocardiography in predicting the postnatal treatment pathway. Methods: PubMed/MEDLINE, CINHAL, Cochrane Library, Academic Search Complete, Web of Science, and Trip Pro were searched for observational studies published before July 2021. Random-effects meta-analysis was performed to identify factors associated with biventricular repair. Results: Eleven individual studies published between 2006 and 2021, including a total of 285 participants (159 biventricular repair; 126 univentricular palliation), met our eligibility criteria. The pooled estimated prevalence of biventricular repair among patients with PSAIVS was 55.6% (95% confidence interval 48.5–62.5%). Those who underwent biventricular repair had greater right to left ventricle and tricuspid to mitral valve dimension ratios, greater TV z score, and longer TV inflow duration/cardiac cycle length by fetal echocardiography. They were also more likely to have significant tricuspid regurgitation and less likely to have ventriculo-coronary connections (VCCs). Conclusions: Commonly obtained fetal echocardiographic measurements have strong associations with treatment pathway choice for patients with PSAIVS. Greater RV growth appears to favor biventricular repair, whereas patients with VCC almost invariably undergo univentricular palliation. Future studies should aim to establish how these fetal echocardiographic parameters might predict outcomes for the two treatment pathways.

Factors causing timely referral for fetal echocardiography in the final diagnosis of congenital heart malformations: A cross-sectional study.

BackgroundCongenital heart disease (CHD) is one of the most frequently inherited illnesses associated with adverse outcomes.ObjectiveThis study aimed to determine the referral cause for fetal echocardiography in the final diagnosis of major CHD.Materials and MethodsIn this cross-sectional study, the data of 1772 pregnant women, referred to a diagnostic clinic during 2017-2020, were reviewed. Data were collected from participants on maternal age, gestational age, history of previous child's heart disease, body mass, the order of birth of children (baby birth rank), type of woman's disease, history of poor midwifery, and nuchal translucency (NT).ResultsOf the 1772 pregnant women, only 33 women (1.8%) had a fetus with CHD major. Abnormality in ultrasound (57.6%), history of abortion (36.4%), increased NT and gestational diabetes (18.2%) and gestational diabetes (18.2%) were identified as the most common referral reasons for fetal echocardiography in these women. Other reasons included a previous child with Down syndrome (12.1%), a previous child with heart disease (12.1%), a history of stillbirth (12.1%), hypothyroidism (12.1%), taking medication during the pregnancy period (9.0%), no underlying disease (9.0%), multiple pregnancies (6.0%), diagnosis with high-risk fetal heart disease (3.0%), high-risk combined aneuploidy screening test in the first trimester (3.0%), in vitro fertilizationpregnancy (3.0%), and having a child with an intellectual disability (3.0%).ConclusionAccording to the results, it can be concluded that ultrasound abnormality, abortion, increased NT and gestational diabetes are the most important factors for referring pregnant women for fetal echocardiography.

Use of fetal tele‐echo at small regional hospitals increases the rate of prenatal diagnosis of congenital heart disease

To improve the rate of prenatal diagnosis of congenital heart disease in Kentucky, 4 fetal tele-echocardiography sites were established at regional hospitals in Kentucky: Ashland in 2011, Paducah in 2014, Lexington in 2014, and Owensboro in 2016. A 13-year retrospective review of medical records at Norton Children's Hospital was performed to identify patients with CHD who had cardiac surgery or intervention prior to one year of age. The rate of prenatal diagnosis prior to establishing any fetal tele-echocardiography sites was compared to the rate of prenatal diagnosis after sites were established. Independent t-tests were used to determine if there was a statistically significant increase in the rate of prenatal diagnosis. 1287 patients had cardiac surgery or cath lab intervention prior to one year of age at our institution from June 2005 to December 2018, and were included in the analysis. 17 patients were excluded due to incomplete medical records. The rate of prenatal diagnosis prior to the implementation of the first fetal tele-echocardiography site was 13.8% and after sites were established the prenatal diagnosis rate was 39.7% (p < 0.01). Increasing the number of fetal tele-echocardiography sites at small regional hospitals in Kentucky was associated with a statistically significant increase in the rate of prenatal diagnosis for patients less than one year of age who had cardiac surgery or cath lab intervention at Norton Children's Hospital in Louisville. Fetal tele-echocardiography is an effective method to improve the rate of prenatal diagnosis in regions served by small regional hospitals with limited access to fetal echocardiography. This article is protected by copyright. All rights reserved.

The Frequency of Single Umbilical Artery in Fetal Ultrasound Among Neonates With Congenital Heart Disease Compared to Neonates Without Congenital Heart Disease

Background and Aim: The need for more fetal echocardiography by a specialist in isolated single umbilical artery (SUA) pregnancies is controversial. Therefore, this study aimed to investigate the frequency of SUA in fetal ultrasound in neonates with congenital heart disease (CHD) compared to neonates without CHD referred to Hazrat Masoumeh Hospital in 2019. Materials and Methods: The files of all the neonates who underwent fetal ultrasound and echocardiography in 2019 were reviewed. Based on the results of the fetal echocardiography, these neonates were divided into two groups with/without cardiac abnormalities. Then, the results of fetal ultrasound performed in terms of the frequency of SUA were examined in the groups, and variables, such as birth, weight, gestational age, and gender were entered into the checklist. Finally, the frequency of SUA in fetuses with/without cardiac abnormalities was compared between the two groups. Results: The mean age of mothers in the SUA group was 32.47±8.7 years and in the normal group was 32.07±11.5 years. A total of 135 boys (54%) and 115 girls (46%) were examined in this study. No statistically significant relationship was found between maternal age (P=0.72), fetal gender (P=0.92), gestational age (P=0.42), and parity (P=0.92) despite the finding of a SUA. In the group of patients with CHD, 12 out of 125 patients (4.8%), and in the group without CHD, five out of 125 patients (2%) had an SUA. Although this number was highest in the group who had CHD, no statistically significant difference was found between the two groups (0.07). Conclusion: The relationship between SUA in a fetus with normal ultrasound and CHD varies significantly with population selection criteria. The risk of CHD after diagnosing SUA in a normal fetus from an unselected population appears to be low and may not warrant specialized fetal echocardiography.

Prenatal Diagnosis and Management of Single-Ventricle Heart Disease.

In the current era, most single-ventricle heart disease (SVHD) is diagnosed prenatally by means of fetal echocardiography. Disparities exist, however, by socioeconomic status and remote location, which require further attention. Prenatal diagnosis affords the opportunity to counsel expectant parents regarding the life-long course of children with SVHD, including the stages of single-ventricle palliation and challenges of the Fontan circulation; to discuss pregnancy management options; and to optimise delivery planning and perinatal care. Prognosis may be refined by specific features on the fetal echocardiogram, such as ventricular morphology, total anomalous pulmonary venous return, and atrioventricular valve regurgitation. Expectant mothers should be referred for evaluation of extracardiac anomalies and/or a genetic syndrome, which also significantly affect outcome. Fetuses with SVHD should be cared for by a multidisciplinary team and ideally delivered at term at or near a cardiac surgical center. Serial echocardiograms refine the anticipated postnatal physiology to optimise transitional care, including the need for prostaglandin or urgent atrial septal intervention in fetuses with hypoplastic left heart syndrome. In selected patients, there may be a role for fetal cardiac intervention to improve mortality or achieve a biventricular circulation after birth. Together, these strategies enhance the preoperative status of the neonate. Recent advances in fetal cardiovascular magnetic resonance imaging have focused on studying the relationships between cardiovascular physiology and fetal growth and development. These novel techniques allow for the exploration of the physiologic effects of SVHD on the brain and open avenues for the investigation of neuroprotective therapies.

Prenatal Diagnosis, Associated Findings, and Postnatal Outcome in Fetuses with Double Inlet Ventricle (DIV).

To assess the spectrum of associated cardiac anomalies, the intrauterine course, and postnatal outcome of fetuses with double inlet ventricle (DIV). Retrospective analysis of prenatal ultrasound of 35 patients with DIV diagnosed between 2003 and 2021 in two tertiary referral centers in Germany. All fetuses underwent fetal echocardiography and a detailed anomaly scan. Postnatal outcome and follow-up data were retrieved from pediatric reports. 33 cases of DIV were correctly diagnosed prenatally. 24 fetuses (72.7%) had a double inlet ventricle with dominant left (DILV), 7 (21.2%) with dominant right ventricular morphology (DIRV), and 2 cases (6%) with indeterminate morphology (DIIV). 4 (16.6%) were Holmes hearts. 5 of the 7 fetuses (71.4%) with DIRV had a double outlet right ventricle (DORV). Malposition of the great arteries was present in 84.8%. Chromosomal abnormalities were absent. Termination of pregnancy was performed in 8 cases (24.2%). 24 fetuses (72.7%) were live-born. 5 (20.8%) were female and 19 (79.2%) were male. The median gestational age at birth was 38+2.5 weeks. All but one child received univentricular palliation. The median follow-up time was 5.83 years with an adjusted survival rate of 91.6% (22 of 24 live-born children). There was one case of Fontan failure at 15.7 years. DIV remains a major cardiac malformation although both prenatal diagnostics and cardiac surgery have improved over the years. The course of pregnancy is commonly uneventful. All children need univentricular palliation. The children are slightly physically limited, develop a normal intellect, and attend school regularly.

P-771 Subfertility versus in vitro fertilization procedures: unravelling the origins of fetal cardiac remodeling in assisted reproductive technologies

Abstract Study question Do spontaneously conceived (SC) fetuses from subfertile couples present signs of cardiac remodeling as those observed after in vitro fertilization (IVF) treatments? Summary answer SC fetuses from subfertile couples do not associate cardiac remodeling, and their cardiac structure and function are similar to those of SC from fertile couples. What is known already Fetuses and children from IVF associate cardiac remodeling and suboptimal function, including dilated atria, more globular and thicker ventricles, reduced longitudinal motion and impaired relaxationin uteroand after birth. Fetal cardiac changes have been demonstrated both after fresh and frozen embryo transfer. The SC fetuses used as ‘controls’ in our previous publications were conceived by fertile couples thus making it difficult to separate the contribution of infertilityper sefrom the IVF procedures on cardiac programming. There are no previous cardiovascular studies investigating the independent effects of infertility in SC fetuses from subfertile couples (time-to-pregnancy (TTP) over 12 months). Study design, size, duration Prospective cohort study of 289 singleton pregnancies recruited from 2017 to 2021, including 96 SC pregnancies from fertile couples (TTP less than 12 months), 97 SC from subfertile couples (TTP over 12 months) and 96 from IVF after fresh ET. Fetal echocardiography was performed in all pregnancies. Epidemiological data and perinatal outcomes were collected in all pregnancies. Participants/materials, setting, methods IVF pregnancies from our centre were identified as eligible at pregnancy diagnosis. Eligible SC pregnancies from fertile and subfertile couples who attended our Maternal-Fetal Unit were invited to participate at third trimester, being matched to the IVF pregnancies by maternal age. Fetal echocardiography was performed at 29-34 weeks of pregnancy to assess cardiac structure and function. Echocardiographic comparisons were adjusted by nulliparity, birthweight centile, gestational age and estimated fetal weight at scan. Main results and the role of chance Parental age, ethnicity, body mass index and smoking exposure, median gestational age and estimated fetal weight were similar in all study groups. There were no significant differences in infertility duration or aetiology between the subfertile and the IVF populations (TTP: subfertile median 30 months [IQR 20-54] versus IVF: 47 [25-61]; p-value=0.052). While both fertile and subfertile SC groups presented similar fetal cardiac results, IVF fetuses showed larger atria (right atria-to-heart ratio: IVF mean 18.9% [SD 3.4] versus subfertile 17.8% [3.5] versus fertile 17.6% [3.3]; adjusted P-value&amp;lt;0.001), more globular ventricles (right ventricular sphericity index: IVF 1.56 [0.25] versus subfertile 1.72 [0.26] versus fertile 1.72 [0.26]; &amp;lt;0.001), and thicker myocardial walls (relative wall thickness: IVF 0.86 [0.22] versus subfertile 0.64 [0.13] versus fertile 0.64 [0.18]; &amp;lt;0.001). Whereas SC fetuses from fertile and subfertile couples had preserved cardiac function, IVF fetuses showed signs of suboptimal systolic and diastolic function with reduced tricuspid ring displacement (IVF 7.26 mm [1.07] versus subfertile 8.04 mm [1.18] versus fertile 7.89 mm [1.51]; &amp;lt;0.001) and increased left myocardial performance index (IVF 0.49 [0.08] versus subfertile 0.45 [0.09] versus fertile 0.45 [0.10]; &amp;lt;0.001). A sub-analysis including only unexplained infertility cases in subfertile SC and IVF groups showed similar results. Limitations, reasons for caution The fetal cardiac changes reported here are subclinical, with most cardiovascular parameters lying within normal ranges. Although echocardiographic changes are recognized as potential cardiovascular risk factors, their association with long-term cardiovascular disease remains to be proven. Wider implications of the findings Subfertility per se does not seem to be associated to fetal cardiac remodeling, which have been previously described in IVF fetuses. Future studies are warranted to further investigate the factors related to fetal cardiac changes associated to ART. Trial registration number Not a trial

Role of prenatal fetal echocardiography in the assessment of intrauterine growth restriction

BackgroundIntrauterine growth restriction (IUGR) is a common diagnosis in obstetrics and carries an increased risk of perinatal mortality and morbidity. Identification of IUGR is crucial because proper evaluation and management can result in a favourable outcome. Cardiovascular dysfunction and remodelling is a central feature of IUGR. The aim of the study was to use the left modified myocardial performance index (MPI), assess cardiac function in foetuses with intrauterine growth restriction (IUGR) compared to healthy foetuses, and to connect the relationship between changes in MPI and perinatal outcome. A prospective study was conducted with 60 singleton foetuses between 24 and 40 weeks of gestation without foetal chromosomal abnormalities or major malformations, divided into two groups: 30 women with intrauterine growth restriction (30 women) and another 30 women with normal pregnancies (foetal growth pattern appropriate for gestational age and normal heart findings with normal sinus rhythm) who were matched for gestational age and served as the controls. Trans-abdominal ultrasound examination was done with 3.5–7-MHz curvilinear Probe (GE Medical US equipment). The umbilical arteries, middle cerebral artery, and ductus venosus all had blood flow velocity waveforms recorded. The pulsatility index (PI), cerebroplacental ratio (CPR), and Doppler velocimetry (DV) of the umbilical artery were all measured. All foetuses had their myocardial performance index assessed. Normal and abnormal umbilical artery(UA) Doppler, as well as normal and abnormal MCA Doppler, were used to examine the intrauterine growth restriction group. Foetal growth restrictions (FGR) foetuses' Mod-MPI values were compared to gestation-matched controls. The outcomes of the perinatal period were documented.ResultsIntrauterine growth restriction foetuses with defective umbilical arteries Doppler had a substantially higher mean left myocardial performance index (mean 0.58 SD 0.093) than healthy foetuses (mean 0.45SD 0.070) (P 0.001). When compared to the control group, IUGR foetuses with abnormal left myocardial performance index had a significantly worse perinatal outcome and higher morbidity. When compared to intrauterine growth restriction foetuses with normal MPI, intrauterine growth restriction foetuses with defective left MPI had a significantly worse perinatal outcome (whether the UA Doppler was normal or abnormal). Based on the perinatal result, the foetal myocardial performance index was linked to the severity of foetal impairment in intrauterine growth restriction foetuses.ConclusionMPI has the potential to be a useful technique for evaluating IUGR pregnancies and predicting neonatal outcome. Within the IUGR foetuses, MPI foetal echocardiographic characteristics can define a high-risk group.

50 Years Ago in TheJournalofPediatrics: Rescuing Infants with Critical Congenital Heart Disease

Engle MA. The salvage of babies and children with congenital heart disease. J Pediatr 1972;81:203-4. Fifty years ago in The Journal, Dr Engle reported early recognition of cyanosis in newborns and prompt highly skilled transport to a cardiac center as cornerstones of rescuing infants with critical congenital heart disease (CCHD). Initial stabilization, followed by a precise diagnosis using cardiac catheterization, allowed for optimal medical or surgical management. A holistic approach to care included long-term psychological well-being and a life as free of disabilities as possible. These core principles continue to form the basis for current management of CCHD. The implementation of a CCHD screen using simple pulse oximetry in the right hand and either foot before hospital discharge has significantly improved the early identification of CCHD and decreased mortality. The screen was adopted by all US states and the District of Columbia by 2018 and is supported by the federal Newborn Screens Save Lives Act of 2008. Significant innovations in ultrasound technology have revolutionized diagnosis by producing real-time images of the congenitally malformed heart. Portable echocardiogram machines can now render highly precise postnatal diagnoses within minutes, without the need for invasive catheterization. Cardiac-gated computed tomography scans or high-resolution cardiac magnetic resonance imaging can add further finer anatomic and functional details. Advances in maternal ultrasound also allow effective screening for major disease with subsequent fetal echocardiography yielding highly precise diagnoses. Delivery at a cardiac center with immediate stabilization of the newborn can be arranged prenatally for complex CCHD. The commercial availability of prostaglandin allows mothers to choose delivery closer to home with subsequent stabilization of infants with known CCHD before transfer to the cardiac center. Prostaglandin can effectively rescue infants missed at hospital discharge who present in the emergency room with shock. With improved survival of patients with CCHD into adulthood, there is increased awareness of neurodevelopmental outcomes with the need for early childhood interventions. Despite significant advances, many challenges remain. CCHD screen is not adopted globally, especially in resource-limited countries where many infants are born at home and with limited transport capabilities. High-quality CCHD imaging, the availability of prostaglandin, in-house pediatric echocardiograms, and prompt transport remain challenging even for high- and middle-income countries. Even with these advances, 97% of infants with non-CCHD but only 75% of those with CCHD will survive to 1 year of age.1Oster M.E. Lee K.A. Honein M.A. Riehle-Colarusso T. Shin M. Correa A. Temporal trends in survival among infants with critical congenital heart defects.Pediatrics. 2013; 131: e1502-e1508Crossref PubMed Scopus (317) Google Scholar We have come far, but there is surely a long road still ahead.

Mediastinal Shift Angle in Fetal MRI Is Associated With Prognosis, Severity, and Cardiac Underdevelopment in Left Congenital Diaphragmatic Hernia.

Objective:Fetal MRI has played an essential role in the evaluation and management of congenital diaphragmatic hernia (CDH). We aimed to investigate whether the mediastinal shift angle (MSA) value was associated with the prognosis and the severity of left CDH and explore the relationship between the MSA value and fetal and neonatal cardiac structures and functions.MethodsFrom January 2012 to December 2020, the fetal MSA values of left CDH in our institution were retrospectively measured. Other prenatal parameters and clinical outcomes of them are collected. We also measured the fetal and postnatal echocardiography parameters to analyze linear correlation with MSA values.ResultsA total of 94 patients with left CDH were included. MSA was significantly higher in the deceased group than in the survived group [((38.3 ± 4.7)° vs. 32.3 ± 5.3)°, p < 0.001]. The MSA value of the high-risk defect group [CDH Study Group (CDHSG) C/D type] was significantly higher than that of the low-risk defect group [CDHSG A/B type; (36.0 ± 4.9)° vs. (30.1 ± 4.8)°, p < 0.001]. The AUC for severity was 0.766 (95% CI, 0.661–0.851, p < 0.0001) and the best cut-off value for MSA was 30.7°. Higher MSA correlates with decreased fetal Z-score of left ventricle (LV) width, the diameter of the mitral valve (MV), peak velocity of MV and tricuspid valve (TV), and neonatal LV end-diastolic diameter (LVEDD) and velocity of tricuspid regurgitation (TR; p < 0.05).ConclusionA high MSA value can effectively predict high-risk defects and high mortality of left CDH. The higher the MSA value, the worse the neonatal conditions, the respiratory and cardiovascular prognosis. The MSA values could reflect the level of left heart underdevelopment, including decreased dimensions and diastolic dysfunction of the left ventricle.

Fetal Ultrasonography Versus Echocardiography in Prenatal Diagnosis of Congenital Heart Disease

Background: To evaluate the ability in initial prenatal diagnosis of congenital heart disease (CHD), the most common considerable and also fatal congenital disorder. It can be achieved by ultrasound (US) or echocardiography (FE) which are performed by radiologists and pediatric cardiologists, respectively. Objectives: The study aimed to compare the results, confirm the modality that promotes the effectiveness of final diagnosis and optimize its management. Methods: A retrospective cross-sectional study on referred pregnant women was conducted in Imam Reza hospital, Mashhad, Iran from 2012 to 2019. Fetal echocardiography was performed by one skilled professional which was compared to ultrasound anomaly scan reports of the same fetuses. Data were analyzed using statistical package for the social sciences (SPSS) ver. 18. The categorical variables were demonstrated as percentages and the agreement between two methods was evaluated by Cohen’s kappa coefficient (K &gt; 0.4, P &lt; 0.05 as significant cut-off). The sensitivity and specialty, as well as the accuracy, positive and negative predictive values, were all calculated. Results: Out of 312 examinations of fetuses, 56 cases were Major cardiac diseases and 62 were Minor cases. FE discovered that 14 out of 33 normal US cases were abnormal. In addition, the US considered 52 cases as structural cardiac abnormalities, of which only 34 cases were verified by FE. The most prevalent cardiac anomaly discovered by FE was the intra-cardiac echogenic focus (12.17%), compared to 7.05% of US diagnoses. The methods considered VSD the most common major, septal CHD with different quantities. The US overdiagnosed 71.4% of cases, whereas underdiagnosed 87.5% of VSDs. The US was unable to detect 11 out of 13 complex-CHDs (84.61%). Except for one percent, the US did not report AVSD. Arrhythmia was detected in 37 cases, with the US correctly diagnosing six of them. The US underdiagnosed 35 major (mostly septal defects 45%) and 26 minor structural cases; additionally, the US overdiagnosed 10 minor and 7 major cases. The methods agreed with the content of 11.53% of the CHD diagnosis. The sensitivity, specificity, and accuracy of the US method in comparison to FE for CHD diagnosis were calculated 62%, 74.2%, and 68.7% respectively. The positive and negative predictive values were 66.1% and 70.27%, respectively. Conclusions: There was a significant correlation between the results of US and FE, but there was no significant agreement in definite diagnosis, particularly for major CHDs. Although the FE is still the best modality; the US by expert sonographers is so contributory and a screening method. It is recommended to do FE at least once during pregnancy, but it is not currently accepted according to the updated guidelines.

Screening and diagnostic imaging at centres performing congenital heart surgery in middle-income countries.

Surgical care for CHD is increasingly available in low- and middle-income countries, and efforts to optimise outcomes are growing. This study characterises cardiac imaging and prenatal diagnosis infrastructure in this setting. An infrastructure survey was administered to sites participating in the International Quality Improvement Collaborative for CHD. Questions regarding transthoracic, transesophageal and epicardial echocardiography, cardiac CT, cardiac magnetic resonance, prenatal screening and fetal echocardiography were included. Associations with in-hospital and 30-day mortality were assessed. Thirty-seven sites in 17 countries responded. Programme size and geography varied considerably: < 250 cases (n = 13), 250-500 cases (n = 9), > 500 cases (n = 15); Americas (n = 13), Asia (n = 18), and Eastern Europe (n = 6). All had access to transthoracic echo. Most reported transesophageal and epicardial echocardiography availability (86 and 89%, respectively). Most (81%) had cardiac CT, but only 54% had cardiac magnetic resonance. A third reported impediments to imaging, including lack of portable machines, age/size-appropriate equipment and advanced cardiac imaging access and training. Only 19% of centres reported universal prenatal CHD screening in their catchment area, and only 46% always performed fetal echocardiography if screening raised concern for CHD. No statistically significant associations were identified between imaging modality availability and surgical outcomes. Although access to echocardiography is available in most middle-income countries; advanced imaging modalities (cardiac CT and magnetic resonance) are not always accessible. Prenatal screening for CHD is low, and availability of fetal echocardiography is limited. Imaging infrastructure in low- and middle-income countries and associations with outcomes merits additional study.

Prenatally diagnosed fetal heart rhythm abnormalities—incidence, diagnosis and outcome

Backrounds: Fetal arrhythmias represent a significant cause of fetal morbidity and mortality and occur in approximately 1–3% of pregnancies. The unknown fetal arrhythmias are the cause of intrauterine fetal demise in as many as 3–10% of cases, as well as the cause of unexplained fetal hydrops or premature births. Methods: A fetal echocardiography test makes it possible to notice structural heart defects at very early stages of pregnancy. The ultrasound heart rate monitoring also involves the use of specific Doppler methods. Heart rhythm disorders may occur in the form of tachycardia (sinus tachycardia (ST), supraventricular tachycardia (SVT) and atrial flutter (AF)) or in the form of bradycardia (sinus bradycardia (SB), atrial bigeminy (AB) and complete AV block). The most frequently diagnosed fetal heart rhythm disorders are isolated extrasystoles with no clinical significance. Results: In this study, we have examined 7863 fetuses (182 were multiple gestations). Out of the total number of examined patients, 572 fetuses (7.23%) had pathological heart features, while 127 (1.61%) had some form of rhythm disorder. Conclusions: The ability to recognize the heart rhythm disorder and commence the treatment in a timely manner increases the treatment success rate.