Objectives This study aimed to establish reference ranges for fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (MAPSE, TAPSE, and SAPSE) in normal pregnant women between 20 and 36 + 6 weeks of gestation. Methods This prospective and cross-sectional study included 360 low-risk singleton pregnancies between 20 and 36 + 6 weeks of gestation. MAPSE, TAPSE, and SAPSE were measured by M-mode in real time in an apical or basal four-chamber view through placing the cursor at the atrioventricular junction, marked by the valve rings at the tricuspid, mitral, and basal septum, respectively. A regression analysis was done to determine the appropriate polynomial equation model for both measurements and standard deviation (SD) values in relation to gestational age (GA). The intra- and inter-observer reproducibility was evaluated using the concordance correlation coefficient (CCC) and limits of agreement (LoA). Results There was a significant positive correlation between MAPSE (r=0.705, p<0.0001), TAPSE (r=0.804, p<0.0001), and SAPSE (r=0.690, p<0.0001) and GA. The mean of each parameter ranged as follows: 2.87-5.56 mm, MAPSE; 3.98-8.07 mm, TAPSE; and 2.34-4.21 mm, SAPSE. Poor/moderate intra- and inter-observer reliability (CCC between 0.70 and 0.90) and poor/moderate agreement of all the tested parameters were evaluated (LoA between 10 and 50%). Conclusions Reference values were established for the fetal MAPSE, TAPSE, and SAPSE between 20 and 36 + 6 weeks of gestation in low-risk pregnant women. These parameters showed poor/moderate reproducibility.

Reference ranges for the fetal mitral, tricuspid, and interventricular septum annular plane systolic excursions (mitral annular plane systolic excursion, tricuspid annular plane systolic excursion, and septum annular plane systolic excursion) between 20 and 36 + 6 weeks of gestation.

Objective. The modified myocardial performance index (mod-MPI) is a non-invasive Doppler index for evaluation of left ventricular systolic and diastolic function. The MPI index is considered to be a reliable early marker of fetal cardiac dysfunction and may indicate the initial stages of adaptation of the heart to various perinatal complications. In order to use the myocardial performance index to assess fetal cardiac function, it’s necessary to determine normal values of MPI in the Russian population and compare the values depending on the period of pregnancy. Materials and methods . A Doppler study was conducted on two hundred fetuses with normal heart anatomy. Determing Mod-MPI values were based on techniques described by Hernandez et al. The measured time intervals: isovolumetric contruction time (ICT), ejection time (ET), isovolumetric relaxation time (IRT). Three consecutive measurements of all parameters were determined and the MPI index was calculated from the average value of each interval according to the formula: PI=(ICT+IRT)/ET. Results . The average value of ICT was 31±3 mc in the 2 nd trimester of pregnancy and 30±3 in the third. The average value of ET was 169±9 mc in the 2 nd trimester of pregnancy and 170±10 in the third. The average value of IRT was 38±4 mc in the 2 nd trimester of pregnancy and 37±4 in the third. The average value of mod-MPI was 0,39±0,03. There were no association between the mod-MPI values and gestational age. Conclusions. The mod-MPI is a marker of fetal myocardial disfunction. The use of myocardial performance index is currently limited due to the lack of normative reference ranges and standardized techniques for measuring the estimated time periods. The modified technique was designed to help measure time intervals for calculation of the MPI.

/pdf/issledovaniia-po-dissertatsionnym-temam-modifitsirovannyi-44nulk4gmw.pdf

Исследования по диссертационным темам модифицированный индекс производительности миокарда у плода: нормальные значения в российской популяции

A high nucleated red blood cell (NRBC) count at birth is taken as a biomarker of fetal hypoxia. In twin-to-twin transfusion syndrome (TTTS), the communication of placental vessels between the donor and recipient twin creates an imbalance of blood flow resulting in anemia in the donor and polycythemia in the recipient. The anemia in donors results in hypoxia. The NRBC count could be used as a biomarker of chronic hypoxia in donor twins. A literature search shows no previous report on the NRBC count at birth comparing donor and recipient twins in TTTS. We present a case of TTTS with a discussion on the pathophysiology of elevated NRBC at birth in donor twins.

Difference in the nucleated red blood cell counts among donor and receipt twins affected by Twin‒Twin transfusion syndrome

Hypoplastic left heart syndrome (HLHS) is a complex congenital heart disease (CHD) involving hypoplasia of the left ventricle (LV), aorta (Ao), and mitral valve. HLHS was uniformly fatal in the past, now survivable with 3-stage surgical palliation. However, there is high morbidity and mortality, with 25% of HLHS patients either dying or having a heart transplant within 1 year of age. The causes for such high morbidity and mortality are not well understood, but the majority of deaths are directly or indirectly related to cardiovascular/hemodynamics causes. Studies in a mouse model of HLHS uncover important contributing factors for single-ventricle patients such as the patient’s intrinsic factors related to mitochondrial dysfunction, and derangements in the early stages of embryonic development. The HLHS mutant mice were noted to have metabolic dysfunction accompanied by cell cycle arrest and cardiomyocyte differentiation defects. Intrinsic cell defects may contribute to cardiac failure in the HLHS population. Moreover, strong evidence of the genetic etiology of HLHS has come from the observation that HLHS has a high recurrence risk and is associated with various chromosomal abnormalities. In this chapter, we will review the basic pathophysiology, pertinent pre-and post-operative managements of HLHS and recent advances derived from the HLHS mouse model. 

Hypoplastic Left Heart Syndrome

Objective: To establish reference ranges for the fetal left ventricle (LV) modified myocardial performance index (Mod-MPI), respective time periods, and right and left atrioventricular peak velocit...

Reference ranges for the left ventricle modified myocardial performance index, respective time periods, and atrioventricular peak velocities between 20 and 36 + 6 weeks of gestation.

Objectives Echocardiography is used to quantitatively characterize cardiovascular function in fetuses with cardiac abnormalities and inform decisions for fetal or perinatal interventions. It is clinically important to understand the reproducibility of these measures, particularly between testers. While studies have reported intra-observer variability and inter-observer variability, little is known about test-retest variability for these measures. We hypothesized that even in a high volume echocardiography laboratory, quantitative measurements will demonstrate higher test-retest variability compared with inter-observer variability and intra-observer variability of the same measurements. Methods Prospective study of uncomplicated, singleton pregnancies to evaluate fetal measures of cardiovascular function obtained by echocardiography. One sonographer obtained predefined variables, and then, a second sonographer obtained the same variables 15 minutes after the first sonographer. Separate data acquisitions were obtained by the two sonographers to evaluate test-retest variability. Intra-observer variability and inter-observer variability were also evaluated. Results Thirty fetuses between 17- and 36-week gestation were enrolled. Time-based variables had the best intra-observer agreement and inter-observer agreement (1.2%-7.4%), while 2D (7.5%-10%), M-mode (4.9%-10.1%), and velocity-time integral (VTI; 2.6%-13.8%) measurements had poorer agreement. For all variables, test-retest agreement was worse (3%-32.1%), particularly for measurement of myocardial performance index (MPI; 19.7%-21.1%), cardiac output estimation (27.2%-27.9%), and VTI-based indices (14.7%-32.1%). Conclusions In a laboratory highly experienced in quantitative fetal echocardiography, intra-observer agreement and inter-observer agreement are good for most quantitative parameters. However, test-retest agreement is fair or poor for several variables, notably the MPI, cardiac output estimation, and VTI-based indices. Understanding how these measures vary between separate acquisitions is important for clinical interpretation and decision making.

Test-retest variability for quantitative two-dimensional and Doppler measurements in the fetus.

A pregnant woman presented at term with a fetus with foramen ovale restriction. We illustrate the contrast between fetal and postnatal echocardiography of this rare entity. (Level of Diffi...

Foramen Ovale Restriction in a Late Gestation Fetus Resembling Hypoplastic Left Heart Syndrome.

Fetal vascular lesions or malformations such as sacrococcygeal teratomas, cervical teratomas, chorioangiomas, and vein of Galen aneurysms are associated with an increased risk of fetal death due to cardiac failure and hydrops. Large vascular lesions have the potential to result in increased cardiac output and volume overload on the fetal heart. As the heart compensates for the increasing blood flow, cardiovascular changes, demonstrable on fetal echocardiography, are likely to occur in the fetus. In the current era of fetal intervention and surgery, it is important to characterize these changes as a means of recognizing cardiac dysfunction and selecting patients for fetal intervention and management. This retrospective study characterizes the echocardiographic findings in fetuses with vascular lesions or malformations using 2D, color, and pulsed-wave Doppler imaging.

https://journals.sagepub.com/doi/pdf/10.1177/8756479311411193

Echocardiographic Findings in Fetuses With Vascular Lesions or Malformations

BACKGROUND Fetal hypoxia has been implicated in fetal growth restriction in congenital heart disease (CHD) and leads to stress erythropoiesis in utero The objective is to assess erythropoiesis and its association with growth in newborns with CHD METHODS Fetuses with prenatally diagnosed CHD from 2013 to 2018 were retrospectively reviewed Pregnancies with multiple gestation, genetic abnormalities, major extra-cardiac anomalies, and placental abruption were excluded Complete blood count tests at birth were compared to published normative values Spearman correlation assessed associations of red blood cell (RBC) indices with birth anthropometrics and prenatal Doppler measures RESULTS A total of 160 newborns were included Median gestational age was 383 (373, 390) weeks Infants ≥37 weeks gestation had lower hemoglobin (Hgb), hematocrit, and elevated nucleated RBC (nRBC), mean corpuscular volume, and mean corpuscular hemoglobin compared to reference No differences in RBC indices were observed in infants <34 and 34-37 weeks gestation There was no difference in Hgb and nRBC between CHD subgroups Neither Hgb nor nRBC were associated with birth anthropometrics or Doppler patterns CONCLUSIONS Term infants with CHD demonstrated multiple alterations in erythrocyte indices suggesting ineffective stress erythropoiesis in late gestation resulting in lower Hgb at birth Altered erythropoiesis was not correlated to growth or Doppler patterns IMPACT Newborns with congenital heart disease (CHD) born at term gestation demonstrated altered erythropoiesis Term newborns with CHD have decreased hemoglobin levels despite having red blood cell indices consistent with stress erythropoiesis, suggesting an incomplete compensatory response to in utero physiologic disturbances associated with CHD The etiology is unknown; however, it may be influenced by multiple risk factors during pregnancy in the maternal-fetal dyad Alterations in red blood cell indices were not associated with outcomes of fetal growth

Altered erythropoiesis in newborns with congenital heart disease.

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Papers

Test-retest variability for quantitative two-dimensional and Doppler measurements in the fetus.

Foramen Ovale Restriction in a Late Gestation Fetus Resembling Hypoplastic Left Heart Syndrome.

Echocardiographic Findings in Fetuses With Vascular Lesions or Malformations

Altered erythropoiesis in newborns with congenital heart disease.