Foramen Ovale Diameter Research Articles

D-Transposition of the great arteries with restrictive foramen ovale in the fetus: the dilemma of predicting the need for postnatal urgent balloon atrial septostomy

ObjectiveRestrictive foramen ovale (FO) in dextro-transposition of the great arteries (d-TGA) with intact ventricular septum may lead to severe life-threatening hypoxia within the first hours of life, making urgent balloon atrial septostomy (BAS) inevitable. Reliable prenatal prediction of restrictive FO is crucial in these cases. However, current prenatal echocardiographic markers show low predictive value, and prenatal prediction often fails with fatal consequences for a subset of newborns. In this study, we described our experience and aimed to identify reliable predictive markers for BAS.MethodsWe included 45 fetuses with isolated d-TGA that were diagnosed and delivered between 2010 and 2022 in two large German tertiary referral centers. Inclusion criteria were the availability of former prenatal ultrasound reports, of stored echocardiographic videos and still images, which had to be obtained within the last 14 days prior to delivery and that were of sufficient quality for retrospective re-analysis. Cardiac parameters were retrospectively assessed and their predictive value was evaluated.ResultsAmong the 45 included fetuses with d-TGA, 22 neonates had restrictive FO postnatally and required urgent BAS within the first 24 h of life. In contrast, 23 neonates had normal FO anatomy, but 4 of them unexpectedly showed inadequate interatrial mixing despite their normal FO anatomy, rapidly developed hypoxia and also required urgent BAS (‘bad mixer’). Overall, 26 (58%) neonates required urgent BAS, whereas 19 (42%) achieved good O2 saturation and did not undergo urgent BAS. In the former prenatal ultrasound reports, restrictive FO with subsequent urgent BAS was correctly predicted in 11 of 22 cases (50% sensitivity), whereas a normal FO anatomy was correctly predicted in 19 of 23 cases (83% specificity). After current re-analysis of the stored videos and images, we identified three highly significant markers for restrictive FO: a FO diameter < 7 mm (p < 0.01), a fixed (p = 0.035) and a hypermobile (p = 0.014) FO flap. The maximum systolic flow velocities in the pulmonary veins were also significantly increased in restrictive FO (p = 0.021), but no cut-off value to reliably predict restrictive FO could be identified. If the above markers are applied, all 22 cases with restrictive FO and all 23 cases with normal FO anatomy could correctly be predicted (100% positive predictive value). Correct prediction of urgent BAS also succeeded in all 22 cases with restrictive FO (100% PPV), but naturally failed in 4 of the 23 cases with correctly predicted normal FO (‘bad mixer’) (82.6% negative predictive value).ConclusionPrecise assessment of FO size and FO flap motility allows a reliable prenatal prediction of both restrictive and normal FO anatomy postnatally. Prediction of likelihood of urgent BAS also succeeds reliably in all fetuses with restrictive FO, but identification of the small subset of fetuses that also requires urgent BAS despite their normal FO anatomy fails, because the ability of sufficient postnatal interatrial mixing cannot be predicted prenatally. Therefore, all fetuses with prenatally diagnosed d-TGA should always be delivered in a tertiary center with cardiac catheter stand-by, allowing BAS within the first 24 h after birth, regardless of their predicted FO anatomy.

Fetal cardiac and neonatal cerebral hemodynamics and oxygen metabolism in transposition of the great arteries.

Hemodynamic abnormalities and brain development disorders have been reported previously in fetuses and infants with transposition of the great arteries and intact ventricular septum (TGA-IVS). A ventricular septal defect (VSD) is thought to be an additional risk factor for adverse neurodevelopment, but literature describing this population is sparse. The objectives of this study were to assess fetal cardiac hemodynamics throughout pregnancy, to monitor cerebral hemodynamics and oxygen metabolism in neonates, and to compare these data between patients with TGA-IVS, those with TGA-VSD and age-matched controls. Cardiac hemodynamics were assessed in TGA-IVS and TGA-VSD fetuses and compared with healthy controls matched for gestational age (GA) during three periods: ≤ 22 + 5 weeks (GA1), 27 + 0 to 32 + 5 weeks (GA2) and ≥ 34 + 5 weeks (GA3). Left (LVO), right (RVO) and combined (CVO) ventricular outputs, ductus arteriosus flow (DAF, sum of ante- and retrograde flow in systole and diastole), diastolic DAF, transpulmonary flow (TPF) and foramen ovale diameter were measured. Aortic (AoF) and main pulmonary artery (MPAF) flows were derived as a percentage of CVO. Fetal middle cerebral artery and umbilical artery (UA) pulsatility indices (PI) were measured and the cerebroplacental ratio (CPR) was derived. Bedside optical brain monitoring was used to measure cerebral hemoglobin oxygen saturation (SO2 ) and an index of microvascular cerebral blood flow (CBFi ), along with peripheral arterial oxygen saturation (SpO2 ), in TGA-IVS and TGA-VSD neonates. Using hemoglobin (Hb) concentration measurements, these parameters were used to derive cerebral oxygen delivery and extraction fraction (OEF), as well as an index of cerebral oxygen metabolism (CMRO2i ). These data were acquired in the early preoperative period (within 3 days after birth and following balloon atrial septostomy) and compared with those of age-matched healthy controls, and repeat measurements were collected before discharge when vital signs were stable. LVO was increased in both TGA groups compared with controls throughout pregnancy. Compared with controls, TPF was increased and diastolic DAF was decreased in TGA-IVS fetuses throughout pregnancy, but only during GA1 and GA2 in TGA-VSD fetuses. Compared with controls, DAF was decreased in TGA-IVS fetuses throughout pregnancy and in TGA-VSD fetuses at GA2 and GA3. At GA2, AoF was higher in TGA-IVS and TGA-VSD fetuses than in controls, while MPAF was lower. At GA3, RVO and CVO were higher in the TGA-IVS group than in the TGA-VSD group. In addition, UA-PI was lower at GA2 and CPR higher at GA3 in TGA-VSD fetuses compared with TGA-IVS fetuses. Within 3 days after birth, SpO2 and SO2 were lower in both TGA groups than in controls, while Hb, cerebral OEF and CMRO2i were higher. Preoperative SpO2 was also lower in TGA-VSD neonates than in those with TGA-IVS. From preoperative to predischarge periods, SpO2 and OEF increased in both TGA groups, but CBFi and CMRO2i increased only in the TGA-VSD group. During the predischarge period, SO2 was higher in TGA-IVS than in TGA-VSD neonates, while CBFi was lower. Fetal cardiac and neonatal cerebral hemodynamic/metabolic differences were observed in both TGA groups compared with controls. Compared to those with TGA-IVS, fetuses with TGA-VSD had lower RVO and CVO in late gestation. A higher level of preoperative hypoxemia was observed in the TGA-VSD group. Postsurgical cerebral adaptive mechanisms probably differ between TGA groups. Patients with TGA-VSD have a specific physiology that warrants further study to improve neonatal care and neurodevelopmental outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Echocardiographic features and outcome of restrictive foramen ovale in fetuses without cardiac malformations

Objective To investigate the clinical significance of restrictive foramen ovale (RFO) monitored by fetal echocardiography during the middle to late stage of pregnancy. Methods The detection rate, echocardiographic features and outcome in fetuses with RFO without cardiac malformations from 7 319 pregnant women received prenatal echocardiography were retrospectively reviewed and analyzed. Results RFO was found in 40 of 7 319 (0.55%) fetuses. The inclusion criteria including a narrow right to left shunt of less than 2.5 mm in diameter across atrial septum, enlarged right atrium, increased right-to-left ventricular size ratio, and increased size ratio of main pulmonary artery to aorta were present in 40 fetuses. The direct ultrasound characters of RFO included limited opening of oval valve (70%) and foramen ovale diameter less than 2.5 mm (30%). And atrial septal aneurysm (62.5%), redundant primum atrial septum (57.5%), abnormal ductus arteriosus (57.5%) might also be present commonly in RFO. As the gestational weeks increased, the size ratio of right-to-left atrium, right-to-left ventricle and the main pulmonary artery to aorta also increased significantly(P=0.004, P<0.001, P<0.001). Among the 40 fetuses with RFO, 21 cases (52.5%) gave birth in full term, 8 cases (20%) which were detected severe tricuspid regurgitation gave birth in early cesarean section, 5 cases (12.5%) had induced labor and 6 cases (15%) were lost in the follow-up. Of the 29 newborns, only 1 case died of heart failure, and the other 28 subjects recovered both from heart structure or cardiac function within four months. Conclusions RFO without cardiac malformations presents echocardiographic features characterized by a narrow right to left shunt of less than 2.5 mm in diameter across atrial septum. Fetal echocardiography can monitor the dynamic change of fetal heart structure and function based on the increase of right heart load and decrease of left heart volume, which has important clinical significance for assessing fetal intrauterine condition and prognosis. Key words: Echocardiography; Restrictive foramen ovale; Fetus; Prognosis

New method to predict need for Rashkind procedure in fetuses with dextro-transposition of the great arteries.

Prenatal congenital heart disease classification systems distinguish between critical dextro-transposition of the great arteries (d-TGA) with restriction of the foramen ovale (FO) (which requires a Rashkind procedure within the first 24 h following delivery) and d-TGA for which surgery is planned (after prostaglandin perfusion or Rashkind procedure later than 24 h after delivery). However, current prenatal diagnostic criteria for postnatal FO restriction in d-TGA are inadequate, resulting in a high false-negative rate. We aimed to identify echocardiographic features to predict the urgent need for Rashkind procedure. We identified retrospectively 98 patients with singleton pregnancy diagnosed prenatally with fetal d-TGA at two European centers from 2006 to 2013. Two groups were compared: (1) those in whom the Rashkind procedure was performed within the first 24 h postnatally; and (2) those who did not undergo a Rashkind procedure before cardiac surgery. Exclusion criteria were: (1) no fetal echocardiography within 3 weeks prior to delivery (n = 18); (2) delivery before 37 weeks of gestation (n = 6); (3) improper or lack of measurement of pulmonary vein maximum flow velocity (n = 10); (4) lack of neonatal follow-up data (n = 9); (5) Rashkind procedure performed more than 24 h after delivery (n = 4). Fifty-one patients met the inclusion criteria: 29 who underwent the Rashkind procedure and 22 who did not. There were no differences between these two study groups in terms of maternal age, gestational age at time of fetal echocardiography, fetal biometric measurements, estimated fetal weight, rate of Cesarean delivery, newborn weight or Apgar score at 1 min. There were also no differences during prenatal life between the two groups in terms of fetal cardiac size (heart area/chest area ratio), rate of disproportion between left and right ventricle, FO diameter and maximum velocity of flow through the FO. However, the pulmonary vein maximum velocity was significantly higher in the group requiring a Rashkind procedure (47.62 ± 7.48 vs 32.21 ± 5.47 cm/s; P < 0.001). The cut-off value of 41 cm/s provided maximum specificity (100%) and positive predictive value (100%) at only a slight cost of sensitivity (82%) and NPV (86%). The prenatal appearance of the FO also differed between the groups, the FO valve being flat in 52% of those requiring a Rashkind procedure. In fetuses with d-TGA, prenatal sonographic findings of increased pulmonary venous blood flow and flattened FO valve were associated with the need for a Rashkind procedure within the first 24 h postnatally; these echocardiographic features could be used to predict prenatally a need for the procedure following delivery. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Abstract 18686: Serial Two Dimensional Echocardiographic Observations and Measurements Obtained by Fetal Echocardiograms: Correlation With Gestational Age

Objective: The purpose of the study was to establish changes that may occur between 20 and 34 weeks of pregnancy in linear measurements of the cardiac chambers, great vessels, aortic isthmus, descending aorta and foramen ovale by fetal echocardiography (FE). Regression analysis was utilized to determine any possible correlation between the linear measurements and gestational age. Methods: Serial FEs were obtained on 2573 normal single pregnancies with accurate gestational ages. FEs obtained using ASE guidelines were divided into 15 groups according to gestational age. Results: Measurements of thoracic diameter, total cardiac diameter, left atrial (LA) and right atrial (RA) diameters, left ventricular (LV) and right ventricular (RV) diameters, and aortic and pulmonary artery diameters significantly increased between 22 and 28 weeks (p &lt; 0.01). Aortic arch isthmus (AoAI), descending Ao diameter, left and right pulmonary artery (PA) diameters and foramen ovale diameter did not change significantly. Between 20 and 34 weeks of pregnancy, RA and RV diameters were always greater than LA and LV diameters, the PA diameter was always greater than Ao diameter, and the AoAI diameter was always greater than the ductal artery (p &lt; 0.01). The ductal artery diameter was always greater than left and right PA Regression analysis between FE dimensions and gestational age showed a significant progressive increase in thoracic and total cardiac diameters, LA and RA diameters, LV and RV diameters, AoAI and descending Ao diameters and ductal artery diameter. Conclusion: FE can accurately assess cardiac structure and is capable of establishing normal reference values of cardiac and great vessel anatomy. As expected, most measurements statistically increase with increasing gestational age.

GW24-e3700 The analysis of Fetal echocardiographic reference value and study on relationship of these measurements with gestational age (I)

ObjectivesTo establish normative reference ranges of fetal cardiac dimensions between 20 and 34 per weeks including: inner diameter of fetal heart and arteries, aortic arch isthmus, descending aorta, ducts artery...

Puncture of Foramen Ovale Cranium in Computed Tomography Three-Dimensional Reconstruction

The study aimed to provide the anatomic data for puncture of foramen ovale cranium in oral cavity. We scan 100 volunteers' skull on computed tomography who have no lesion of skull base, of which the images were for three-dimensional reconstruction. The following observations and measurements were carried out: the shape, size of foramen ovale cranium, and the angle and length of puncture line. The results we got are the following: foramen ovale cranium appears as oval, kidney shape, round, pear shape, and strip shape. Foramen ovale diameter is 8.20 ± 1.54 mm, and width is 4.08 ± 0.73 mm for men and 4.23 ± 0.79 mm for female. The distance from the center of foramen ovale to the maxillary second molar is 51.65 mm for male and 48.77 mm for female. The puncture line is from the center of foramen ovale to the maxillary second molar. The angle of the puncture line with the vertical plane, which is through the midpoint of supraorbital margin and the infraorbital margin, is 40.27 degrees for men and 37.31 degrees for women. The angle of the puncture line with the horizontal plane is 49.37 degrees for men and 52.26 degrees for women. The angle of the puncture line with the sagittal plane is 3.78 degrees. All data between the left and right sides have no statistically significant difference (P > 0.05), but the diameter, the length of the puncture, and the angle of puncture line with the horizontal and vertical have significant differences on sex (P < 0.01). The anatomic character of the foramen ovale cranium has important value on the accuracy of puncture for the treatment of trigeminal neuralgia.

Benign Outcome of Pulmonary Hypertension in Neonates With a Restrictive Patent Foramen Ovale Versus Result for Neonates With an Unrestrictive Patent Foramen Ovale

Premature closure or restriction of foramen ovale (FO) is a rare but known entity. FO diameter <2 mm and Doppler velocity >120 cm/s, diameter <3 mm with Doppler velocity measured gradient >5 mmHg have all being used by various authors to describe this entity. Some neonates with restrictive FO have been noted to have severe pulmonary hypertension with no clinical signs or symptoms and with spontaneous resolution without any intervention. Seven consecutive neonates were indentified in the database between 01/01/2003 and 06/30/2010 with diagnosis of restrictive PFO (diameter <2 mm) with structurally normal heart and their initial and follow-up echocardiogram as well as hospital medical records were reviewed. As a control, seven neonates with diagnosis of pulmonary hypertension and respiratory distress syndrome or meconium aspiration syndrome were randomly selected. Eighty-six percent of the patients in the control group were symptomatic and required treatment as compared to 14% in the restrictive FO group (p = 0.03). Further, the fall in the peak instantaneous pulmonary artery pressure on follow-up echocardiogram was greater in the restrictive FO group compared with the non-restrictive group (p = 0.03). Patients with pulmonary hypertension and a restrictive FO with no other associated congenital heart disease and/or lung pathology behave differently when compared to neonates with non-restrictive FO and pulmonary hypertension with associated lung disease. They seldom manifest symptoms requiring intervention and tend to show a faster drop in their pulmonary artery pressure toward the normal.

Bases morfológicas para o estudo do septo interatrial no feto humano

To describe morphological features of the interatrial septum in normal fetuses, especially foramen ovale (FO) and septum primum (SP), in order to compare septum primum excursion with foramen ovale diameter. Septum primum excursion (SPE) toward the left atrium (LA) and foramen ovale diameter (FOD) were measured in the hearts of ten formaldehyde-fixed human fetuses ranging from 28 to 36 weeks of gestation. Histological sections were obtained from the foramen ovale (FO), septum primum (SP), septum secundum (SS), left atrium (LA), and right atrium (RA). FOD and SPE measurements were the following: FOD 3.1-3.5 mm and SPE 2.8-3.1 mm in three fetuses with presumed gestational age (GA) of 28 weeks; FOD 3.3-3.5 mm, and SP excursion 4.0-5.0 mm in four fetuses with presumed GA of 34 weeks, plus FOD 3.3-4.5 mm and SPE 6.0-9.0 in three fetuses with presumed GA of 36 weeks. Cardiac muscular fibers were identified in both the septum primum and secundum. Based on its muscular components, it may be suggested that SP is active in character, influencing blood flow through the FO, SP mobility, and its excursion into the LA.

A mobilidade do Septum primum não depende do diâmetro do forame oval em fetos normais

To test the hypothesis that a correlation exists between the maximum foramen ovale diastolic diameter and the excursion index (EI) of the septum primum in normal fetuses. One hundred and two normal fetuses with gestational ages ranging from 20 to 40 weeks were submitted to echocardiography. The foramen ovale diameter and the "maximal excursion" of the septum primum were measured in a 4-chamber view. The data were analyzed by Pearson's correlation coefficient. The mean foramen ovale (FO) diameter was 5.06 +/- 1.29 mm; the maximal excursion of the septum primum was 5.42 +/- 1.41 mm; the left atrium diameter 11.47 +/- 2.76 mm; the septum primum "excursion index" was 0.48 +/- 0.09. Mean FO/EI ratio was 11.35 +/- 3.94 mm. No FO/EI correlation (r = -0.03) existed, and a weak foramen ovale/left atrium correlation (r = 0.31) was observed, as well as a weak foramen ovale/excursion of septum primum correlation (r = 0.21). Septum primum mobility does not depend on the foramen ovale diameter in normal fetuses, suggesting that the modifications of its diastolic displacement is not influenced by the size of the interatrial opening.

Intrauterine pulmonary venous flow and restrictive foramen ovale in fetal hypoplastic left heart syndrome

ObjectivesWe sought to determine whether direct foramen ovale (FO) assessment or pulmonary venous (PV) flow patterns in fetal hypoplastic left heart syndrome (HLHS) correlate with clinical markers of postnatal left atrial (LA) hypertension severity associated with restrictive FO. BackgroundRestrictive FO places a newborn with HLHS at high risk of mortality and morbidity. MethodsWe reviewed the prenatal and postnatal echocardiograms and outcomes of 45 fetuses with variants of HLHS diagnosed since May 1999 to determine whether direct FO assessment or PV flow patterns correlate with clinical LA hypertension after birth. ResultsDirect FO assessment in utero showed a poor correlation with postnatal FO size, Pao2, base excess, and the need for atrial septoplasty (p > 0.05). In 40 fetuses with available PV spectra, three PV flow patterns were observed: 1) continuous forward flow with a small a-wave reversal (velocity time integral [VTI] for reverse/forward flow [VTIR/VTIF ratio <0.18]); 2) continuous forward flow with increased a-wave reversal (VTIR/VTIF ratio ≥0.18); and 3) brief to-and-fro flow. Among 19 live-borns, the postnatal FO diameter was smaller in patients with type B than in those with type A flow (1.6 ± 1.6 mm and 4.5 ± 2.1 mm, respectively; p = 0.0015), and all patients with type C flow had an intact atrial septum. All three patients with type C flow were critically ill at birth, requiring emergent atrial septoplasty, and two died after heart transplantation, whereas patients with type A or B flow were clinically stable, with only one postoperative death. ConclusionsPrenatal PV flow patterns in HLHS identify the fetus at risk of severe LA hypertension at birth.

441 Comparison of multiplane transesophageal echocardiography with balloon sizing in assessing patent foramen ovale diameter

441 Comparison of multiplane transesophageal echocardiography with balloon sizing in assessing patent foramen ovale diameter

Structural changes in pulmonary vessels and coronary arteries in hypoplastic left heart syndrome

In order to correlate gross morphological features with pulmonary and coronary vasculature changes in hypoplastic left heart syndrome (HLHS) 15 heart-lung necropsy specimens from neonates were analysed. Histology of left atrium wall, lung vessels with pulmonary arteriolar disease morphometric grading, study of intra and extra pulmonary wall veins and coronary arteries were recorded. Classic HLHS was observed in 11, and DORV with mitral atresia in 4, the foramen ovale (FO) being the only left atrium outflow tract in all. All specimens had increased % of thickness and muscular extension of arterioles and increased wall thickness of pulmonary veins, but severer arteriolar and venous changes with left atrium fibrosis were noticed in 8 specimens with either closed FO (3 cases) or mean FO diameter (d) of 5 mm when compared with specimens with mean FOd of 9 mm. Coronary arteries histology disclosed in 4 of 8 specimens with opened but hypoplastic mitral valve, intima proliferative changes with lumen narrowing, not observed in 7 specimens with mitral valve atresia. We concluded that in HLHS closed or restrictive FO and permeable mitral valve may predispose neonates to respiratory complications, right ventricle abnormal function and arrhythmias, specially after cardiac surgery.