Urgent neonatal balloon atrial septostomy in simple transposition of the great arteries: predictive value of fetal cardiac parameters

Fetal cardiac function in pregnancy affected by congenital heart disease: protocol for a multicentre prospective cohort study

BACKGROUND

Congenital heart disease (CHD) is the most common fetal malformation, and it can result first in cardiac remodeling and dysfunction and later in cardiac failure and hydrops. A limited number of studies have evaluated cardiac function in fetuses affected by CHD. Functional parameters could potentially identify fetuses at risk of cardiac failure before its development. However, these techniques have not translated from research to clinical settings, due to a lack of standardization and poor repeatability. We seek to evaluate whether application of automated techniques to a cohort with fetal pathology could overcome these factors.

METHODS

A multicenter cohort study will be carried out in eight teaching hospitals across Europe, Australia, and Middle East. Based on a previous observed standard deviation, a total sample of 381 pregnancies is required to achieve 80% power to detect a difference of 0.03 in mean myocardial performance index (MPI) with a two-sided type I error rate of 5%. After adjustments allowing for patient exclusions or incomplete datasets, a total of 330 healthy singleton pregnancies and 165 diagnosed with CHD will be recruited. Two fetal cardiac function evaluations at 19 + 6-28 + 6 and 32 + 6-36 + 6 weeks will be offered assessing automated pulsed wave doppler (PWD) MPI, spatio-temporal image correlation (STIC) annular and septal plane excursion (TAPSE, MAPSE and SAPSE), alongside cardiac morphometric and Doppler evaluations of flow across the valves. A secondary nested case-control study will evaluate fetuses with hydrops compared to those without. Differences in functional parameters between cases and controls and over time will be assessed using generalized linear mixed models. Logistic regression will estimate the association between cardiac parameters and hydrops' incidence.

DISCUSSION

This study will provide evidence as to whether automated functional parameters could be significantly different in pregnancy affected by CHD versus healthy pregnancies. The primary objective is to compare automated PWD-MPI and STIC TAPSE, MAPSE and SAPSE in fetuses affected by CHD versus healthy. The secondary objective is to estimate whether these automated parameters could improve the predictive value of the classical cardiovascular profile score in case of hydrops.

TRIAL REGISTRATION

The study protocol has been registered in the ClinicalTrials.gov Protocol Registration System, identification number NCT05698277.

Fetal Speckle Tracking Echocardiography Measured Global Longitudinal Strain and Strain Rate in Congenital Heart Disease: A Systematic Review and Meta-Analysis

Fetal two-dimensional speckle tracking echocardiography (2D-STE) is a novel technique that provides information on fetal heart function by measuring global longitudinal strain (GLS) and global longitudinal strain rate (GLSR). These features assess the longitudinal deformity of the fetal cardiac wall. 2D-STE is shown to be of prognostic value in children and adults with congenital heart disease (CHD). Therefore, its importance in fetal life should also be considered. This systematic review and meta-analysis provides an overview of the literature on 2D-STE (GLS/GLSR) in fetuses with CHD, focusing on the left and right ventricles (LV/RV). Findings indicated that LV-GLS was significantly lower in fetuses with coarctation of the aorta (CoA) and Tetralogy of Fallot (ToF) compared to controls. Conversely, fetuses with a single left ventricle exhibited higher LV-GLS. RV-GLS was significantly lower in fetuses with hypoplastic left heart syndrome (HLHS) and ToF compared to controls. LV-GLSR was significantly lower in fetuses with CoA. Overall, considerable heterogeneity was observed, possibly due to differences in study design. More prospective longitudinal studies on 2D-STE in fetuses with CHD, considering heterogeneity parameters, could offer better insights into this promising technique.

Role of maternal hyperoxygenation in predicting need for postnatal balloon atrial septostomy in fetal d-transposition of the great arteries

OBJECTIVE

Predicting whether postnatal balloon atrial septostomy (BAS) will be necessary for fetuses with dextro-transposition of the great arteries (d-TGA) remains challenging. We sought to determine whether fetal echocardiographic measurements obtained during maternal hyperoxygenation (MH) can improve our ability to predict the need for postnatal BAS.

METHODS

This was a retrospective, single-institution review of d-TGA fetuses whose mothers had undergone MH at 33-38 weeks' gestation at the Children's Hospital of Philadelphia, between 1 January 2017 and 30 March 2020. All fetal d-TGA cases had either an intact ventricular septum or small ventricular septal defect measuring < 3 mm. Patent foramen ovale (PFO) size, measured by two-dimensional imaging (2D) and by color Doppler, and patent ductus arteriosus (PDA) shunting (antegrade vs bidirectional) were assessed in room air (RA) and during MH. BAS status and timing were recorded.

RESULTS

Of 41 fetal d-TGA cases in the cohort, 23 underwent postnatal BAS, while 18 did not, and 14 subjects underwent emergent BAS within 3 h of delivery. On univariate analysis, PFO size measured both in RA and during MH and antegrade shunting in the PDA during MH predicted BAS. During MH, median PFO size by 2D was significantly smaller in fetuses which underwent emergent BAS compared to fetuses which did not undergo BAS (2.5 (interquartile range (IQR), 2.0-3.0) mm vs 4.1 (IQR, 3.4-5.0) mm; P < 0.001). On cut-point analysis, PFO size by 2D during MH of ≤ 3.2 mm predicted the need for emergent BAS with a sensitivity of 93% (95% CI, 66-100%) and a specificity of 78% (95% CI, 58-91%).

CONCLUSIONS

In fetuses with d-TGA, measurement of PFO size and direction of PDA shunting during MH improves our ability to predict the need for postnatal BAS, although additional study is needed. We propose incorporating third-trimester MH when planning delivery of a d-TGA fetus. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Perinatal Cardiac Functional Adaptation in Hypoplastic Left Heart Syndrome: A Longitudinal Analysis

BACKGROUND

The perinatal transition is characterized by acute changes in cardiac loading. Compared with normal newborn combined cardiac output (CCO), single right ventricular (RV) output of neonates with hypoplastic left heart syndrome (HLHS) is markedly greater. The aim of this study was to examine the mechanisms of cardiac adaptation that facilitate this perinatal transition from late fetal to early neonatal life in HLHS.

METHODS

Prospectively recruited pregnancies complicated by fetal HLHS (n = 35) and healthy control subjects (Ctrl; n = 17) underwent serial echocardiography in late gestation (38 ± 1 weeks) and 6, 24, and 48 hours after birth. Cardiac function was assessed using conventional, Doppler tissue, and speckle-tracking echocardiography.

RESULTS

Term fetuses with HLHS had RV output comparable with Ctrl CCO via higher stroke volume. Compared with both left ventricular and RV indices of Ctrl, they exhibited globular and dilated right ventricles with reduced relative wall thickness (0.40 ± 0.08 vs 0.49 ± 0.10, P < .01), increased Tei index' (HLHS vs Ctrl left ventricle/Ctrl right ventricle: sphericity index, 0.9 ± 0.25 vs 0.5 ± 0.10/0.6 ± 0.11; RV area index, 28 ± 6 vs 15 ± 3/17 ± 5 cm2/m2; Tei index', 0.65 ± 0.11 vs 0.43 ± 0.07/0.45 ± 0.09; P < .0001 for all). Neonates with HLHS generated elevated RV cardiac output compared with Ctrl CCO via higher heart rate and stroke volume, with further RV dilatation, increased longitudinal systolic strain at 48 hours (-17 ± 4% vs -14 ± 3%/ 14 ± 5%) with reduced circumferential and rotational myocardial deformation and altered diastolic function. Neonates with HLHS also demonstrated right atrial enlargement with increased longitudinal strain: 6 hours (33 ± 12% vs 26 ± 6%), 24 hours (37 ± 15% vs 26 ± 13%), and 48 hours (38 ± 11% vs 24 ± 13%) (P < .0001).

CONCLUSIONS

Term fetuses with HLHS exhibit altered RV geometry and RV systolic and diastolic functional parameters. After birth, further alterations in these cardiac parameters likely reflect adaptation to acutely altered RV loading from increasing cardiac output and pulmonary artery flow demands.

[Balloon atrioseptostomy under echocardiographic and fluoroscopic guide in patients with congenital heart diseases under 3 months in a national reference pediatric center]

Objective

Balloon atrioseptostomy is an emergency procedure in congenital heart diseases requiring an atrial septal defect to increase cardiac output in right-sided obstructive lesions or to improve mixing in patients with transposition of the great arteries. This procedure is currently performed with both fluoroscopy and echocardiography. The main objective is to describe our experience with the use of balloon atrioseptostomy under echocardiographic and fluoroscopic guidance in patients under 3 months.

Materials and methods

A descriptive, comparative and retrospective study in patients in whom balloon atrioseptostomy was performed under echocardiographic and fluoroscopic guidance between 2018 and 2023 in a referral hospital in Peru.

Results

36 patients were analyzed, of which 21 were from the fluoroscopy group. and 15 patients from the echocardiography group. More than 2/3 of the cases were males, and more than 60% of patients in both groups had transposition of the great vessels. No significant differences were found in terms of ventilatory support and inotropic support. The success of the procedure was 100% in both groups, without complications.

Conclusion

Both balloon atrioseptostomy performed by fluoroscopy and those performed by echocardiography were successful and without complications, emphasizing that the one performed by echocardiography is performed in the patient's crib, avoiding the transfer of the critical unit to the angiography room and without the use of radiation.

Delivery room and early postnatal management of neonates with congenital heart disease

Advancements in prenatal detection have improved postnatal outcomes for patients with congenital heart disease (CHD). Detailed diagnosis during pregnancy allows for preparation for the delivery and immediate postnatal care for the newborns with CHD. Most CHDs do not result in hemodynamic instability at the time of birth and can be stabilized following the guidelines of the neonatal resuscitation program (NRP). Critical CHD that requires intervention immediately after birth is recommended to be delivered in facilities where immediate neonatal and cardiology care can be provided. Postnatal stabilization and resuscitation for these defects warrant deviation from the standardized NRP. For neonatal providers, knowing the diagnosis of fetal CHD allows for preparation for the anticipated instability in the delivery room. Prenatal detection fosters collaboration between fetal cardiology, cardiology specialists, obstetrics, and neonatology, improving outcomes for neonates with critical CHD.

How reliably does prenatal echocardiography predict urgent balloon atrial septostomy in fetuses with d-TGA?

OBJECTIVE

To analyze the prenatal and postnatal outcomes of fetuses with d-TGA and to determine whether prenatal echocardiography may predict postnatal urgent BAS.

STUDY DESIGN

A retrospective study of fetuses with d-TGA, for which fetal echocardiography was performed at our tertiary hospital from January 2018 to May 2023. We assessed the appearance of the septum primum and the FO flap in the four-chamber view as to whether the FO had a restrictive appearance during measurement of the diameter of the FO at its maximal angle to the attachment point. Color Doppler was used to detect VSDs and measure its diameter both in the four-chamber view and when visualizing the outlets of the great arteries in the sagittal section of the heart.

RESULTS

During the study period, 64 fetuses were diagnosed with d-TGA, which was also confirmed postnatally. Of these, 16 fetuses were excluded due to additional cardiac anomalies or the inability to reach the mother. In total, 48 cases were included in this series. In our study, the FO diameter was significantly decreased in the urgent BAS group, compared with the fetuses without urgent BAS (5.1 mm vs 6.3 mm). A cut off of 6 mm for the FO diameter (sensitivity, 73.3 %; specificity, 72.2 %; area under the curve [AUC], 0.764) and 3.2 mm for the VSD diameter (sensitivity, 75 %; specificity, 75 %; AUC, 0.728) suggested urgent BAS.

CONCLUSION

Prenatal echocardiography performed after 37 weeks of gestation in fetuses with d-TGA provides valuable information to estimate the need for postnatal urgent BAS that would prevent immediate life-threatening complications.

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

OBJECTIVE

Restrictive 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.

METHODS

We 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.

RESULTS

Among 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).

CONCLUSION

Precise 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.

Assessment and management of neonates with unrepaired congenital heart disease

PURPOSE OF REVIEW

To review preoperative assessment and management of neonates with congenital heart disease (CHD).

RECENT FINDINGS

The spectrum for neonates with CHD can be wide and complex. An in-depth understanding of their physiology is the first step in assessing their hemodynamics and developing an effective therapeutic strategy.

SUMMARY

There is significant heterogeneity in the anatomy and physiology in newborns with CHD. Their complex pathophysiology can be simplified into seven basic subtypes, which include systolic dysfunction, diastolic dysfunction, excessive pulmonary blood flow, obstructed pulmonary blood flow, obstructed systemic blood flow, transposition physiology, and single ventricle physiology. It is important to note these physiologies are not mutually exclusive, and this review summarizes the hemodynamic and therapeutic strategies available for the preoperative neonate with CHD.

Prenatal prediction of Shone's complex. The role of the degree of ventricular disproportion and speckle-tracking analysis

OBJECTIVES

Shone's complex (SC) is characterized by sequential obstructions of left ventricular (LV) inflow and outflow. It can be associated with poor long-term prognosis when compared to Simple-Aortic Coarctation (S-CoA). We aimed to assess whether the degree of ventricular disproportion and 2D-speckle-tracking echocardiography (2D-STE) could improve the accuracy of prenatal prediction of SC.

METHODS

75 consecutive fetuses were retrospectively enrolled from January 2010 to June 2021. Fetuses were divided into 4 groups (Group 1: SC; Group 2: S-CoA; Group 3: False Positive-Coarctation of the Aorta [FP-CoA]; group 4: controls). Comparisons for echocardiographic measures and myocardial deformation indices were performed. A receiver operating characteristic (ROC) analysis was performed on the MV/TV (mitral valve/tricuspid valve ratio) and LV GLS (global longitudinal strain) values to identify cut-offs to separate group 1 and 2 fetuses.

RESULTS

SC fetuses showed a significant reduction in MV/TV when compared to S-CoA and FP-CoA fetuses (p<0.001). LV GLS in SC fetuses was significantly reduced compared to S-CoA fetuses (-13.3 ± 2.1% vs. -17.0 ± 2.2%, p=0.001). A cut-off value of 0.59 for MV/TV and -15.35% for LV GLS yielded a sensitivity of 76 and 82% and a specificity of 71 and 83% respectively in separating SC vs. S-CoA fetuses.

CONCLUSIONS

SC fetuses showed a more severe degree of ventricular disproportion and a lower LV GLS compared to S-CoA, FP-CoA and control fetuses. MV/TV and GLS are both predictors of SC. These findings may improve the quality of prenatal parental counselling.

Speckle tracking analysis to evaluate the size, shape, and function of the atrial chambers in fetuses with d-transposition of the great arteries to predict the need for neonatal urgent balloon atrial septostomy

INTRODUCTION

Speckle tracking analysis was used to evaluate right (RA) and left (LA) atria size, shape and contractility to create a probability calculator to identify fetuses at risk for urgent neonatal balloon atrial septostomy (BAS).

METHODS

The study group consisted of 39 fetuses with D-TGA, of which 55% (N = 22) required neonatal BAS and 45% (N = 17) did not. The RA and LA end-diastolic areas, lengths, widths, and sphericity indices as well as global, longitudinal, and transverse contractility were measured with speckle tracking analysis. The z-scores of the measurements were compared to 200 controls. Logistic regression analysis of the computed z-score measurements was performed to separate fetuses requiring urgent neonatal atrial BAS from those who did not.

RESULTS

The following z-score values for all fetuses with D-TGA, irrespective of whether they required neonatal BAS, that were significantly less than controls: RA base sphericity index, basal-apical length fractional shortening, fractional area change, lateral wall annular plane systolic excursion (APSE), and longitudinal reservoir strain; LA mid-chamber width, fractional shortening, ejection fraction, basal-apical length fractional shortening, atrial ejection volume, septal wall APSE, and reservoir strain. The following z-score values were significantly larger than control values: RA/LA mid-chamber width, RA/LA base width, and RA mid-chamber length. Logistic regression analysis identified the following five measurements that correctly identified 19 of 22 fetuses requiring urgent neonatal atrial BAS with a sensitivity of 86.4%, a false-positive rate of 11.8% and a positive predictive value of 90.4%: (1) LA mid-chamber transverse fractional shortening, (2) RA mid-chamber end-diastolic width, (3) RA basal-apical length fractional shortening, (4) RA mid-chamber fractional shortening, and (5) RA fractional area change.

CONCLUSION

Using the measurements described in this study identified significant differences between all fetuses with D-TGA and controls, as well as identified measurements that predicted the probability of D-TGA fetuses requiring neonatal septostomy.

Speckle Tracking Analysis in Fetuses with D-Transposition: Predicting the Need for Urgent Neonatal Balloon Atrial Septostomy

INTRODUCTION

Speckle tracking analysis of the endocardium of the right (RV) and left (LV) ventricles was used to evaluate the size, shape, and contractility of these chambers in fetuses with D-Transposition of the great arteries (D-TGA) to identify fetuses that would require emergent balloon atrial septostomy (BAS) after birth.

METHODS

This was a retrospective analysis of fetuses with D-TGA and intact ventricular septum that were divided into 2 groups. Group 1 underwent urgent BAS after birth because of a restrictive atrial septum and group 2 did not. Using speckle tracking analysis, the end-diastolic and end-systolic RV and LV areas, lengths, widths, sphericity indices, and contractility were computed. Logistic regression analysis was performed to identify fetuses who would require urgent neonatal BAS.

RESULTS

Of the 39 fetuses with D-TGA, 55% (n = 22) required urgent neonatal BAS (group 1) and 45% (n = 17) (group 2) did not. When comparing D-TGA groups 1 and 2, differences were seen in RV and LV area, sphericity index for segment 1 of the LV, LV fractional area of change and free wall annular plane systolic excursion, fractional shortening for LV segment 12, and RV free wall strain. Regression analysis of these measurements identified 91% of neonates who underwent BAS, with a false-positive rate of 12%.

CONCLUSION

Using speckle tracking analysis to evaluate the RV and LV, measurable differences were identified for the RV and LV size, shape, and contractility between fetuses who underwent neonatal urgent BAS vs. those who did not require this procedure.

Functional assessment of atrial M-mode in 3rd trimester in the context of postnatal balloon atrial septostomy in fetuses with simple dextro-transposition of the great arteries

OBJECTIVE

This study aimed to identify new functional echocardiographic features of fetal foramen ovale (FO) to predict the need of urgent balloon atrial septostomy (BAS) in neonates with simple dextro-transposition of the great arteries (d-TGA).

METHOD

Single-center prospective study of fetuses, who had prenatal echocardiographic examination <30 days before delivery and fetal diagnosis of simple d-TGA. The subjects were divided according to the need of BAS within the first 24 h after neonatal birth and before arterial switch operation. We analyzed following parameters: FO diameter, pulmonary venous maximal velocity, new FO flap tracings index analyzed by M-mode echocardiography.

RESULTS

Out of 130 fetuses, 12 patients were included. Cutoff value of FO index provided maximum sensitivity (100%) and negative predictive value (100%) and cutoff value of FO index multiplied by FO diameter provided maximum specificity (100%) and positive predictive value (100%) in fetuses with fetal d-TGA in predicting need of urgent BAS.

CONCLUSION

FO index could potentially be used to predict postnatal haemodynamic stability in fetuses with simple d-TGA. FO index multiplied by FO diameter could potentially be used to predict prenatally the need of urgent BAS following the birth.

Prenatal sonography of the foramen ovale predicts urgent balloon atrial septostomy in neonates with complete transposition of the great arteries

BACKGROUND

Hypoxia caused by inadequate intracardiac mixing owing to a restrictive foramen ovale is a potentially life-threatening complication in neonates with dextro-transposition of the great arteries. An urgent balloon atrial septostomy is a procedure of choice in such cases, but dependent on the availability of a 24-hour interventional cardiology facility. The prenatal identification of predictors for an urgent balloon atrial septostomy at birth would help in optimizing the management of these neonates, minimizing the risk of hypoxic damage.

OBJECTIVE

This study aimed to predict with prenatal echocardiography the need of urgent balloon atrial septostomy in neonates with dextro-transposition of the great arteries.

STUDY DESIGN

This was a retrospective cohort study of patients with a prenatal diagnosis of transposition of the great arteries that were delivered in our center between 2010 and 2019, for whom fetal ultrasound echocardiograms obtained at less than 3 weeks before delivery were available. The following parameters were systematically obtained at fetal echocardiography: size and appearance of the foramen ovale, septum primum excursion (foramen ovale flap angle at the maximal excursion), diameters of the atria, and size of the ductus arteriosus. Balloon atrial septostomy was defined as urgent if performed within 12 hours from birth in neonates with restrictive foramen ovale. Neonatal follow-up was obtained through medical records analysis.

RESULTS

From November 2007 to April 2019, 160 fetuses with complete transposition of the great arteries were referred to our echocardiography laboratory and 60 of these were included in the analysis; 27 underwent urgent balloon atrial septostomy, 11 elective balloon atrial septostomy, and 22 no balloon atrial septostomy. The size of the foramen ovale was the best predictor of an urgent balloon atrial septostomy. A measurement of >6.5 mm had a sensitivity of 100% and a false positive rate of 45%.

CONCLUSION

Fetal echocardiography predicts the need of an urgent balloon atrial septostomy in fetuses with dextro-transposition of the great arteries although with a limited precision. In our experience, a measurement of the foramen ovale within 3 weeks of delivery had the greatest accuracy.