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Biancardi M, de Sa RAM. Behavior of fetal longitudinal myocardial fibers assessed by speckle tracking to obtain strain and strain rate values for low-risk pregnancies. J Perinat Med 2020; 48:144-152. [PMID: 31834865 DOI: 10.1515/jpm-2019-0342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/05/2019] [Indexed: 01/27/2023]
Abstract
Objective To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results.
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Affiliation(s)
- Mariana Biancardi
- Fernandes Figueira Institute - FIOCRUZ, Av. Rui Barbosa, 716 - Flamengo, Rio de Janeiro, RJ 20021-140, Brazil
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Öcal DF, Yakut K, Öztürk FH, Öztürk M, Oğuz Y, Altınboğa O, Çelen Ş. Utility of the modified myocardial performance index in growth-restricted fetuses. Echocardiography 2019; 36:1895-1900. [PMID: 31592558 DOI: 10.1111/echo.14489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/01/2019] [Accepted: 09/03/2019] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES The modified myocardial performance index (Mod-MPI) can be used to assess myocardial function. Fetal growth restriction can affect fetal myocardial function, thereby altering the Mod-MPI. The results of previous studies on the utility of the Mod-MPI in growth-restricted fetuses are conflicting. The aim of this study was to calculate the left modified-MPI in growth-restricted fetuses and to compare the results with those of healthy fetuses. METHODS This was a prospective cross-sectional case-control study. In total, 40 women with growth-restricted fetuses and 40 women with fetuses of normal weight (controls) at 29-39 gestational weeks were enrolled in the study. An experienced obstetrician calculated the Mod-MPI for each fetus. Women with systemic diseases or fetuses with chromosomal/structural abnormalities were excluded from the study. The results of Mod-MPI measurements of the two groups were compared. RESULTS The mean single deepest vertical pocket (SDVP) of amniotic fluid, estimated fetal weight (EFW), and isovolumetric relaxation time (IRT) was significantly lower in the fetal growth restriction (FGR) group as compared with these parameters in the control group (P < .05). The uterine artery (UtA) pulsatility index (PI) was significantly higher in the FGR group as compared with that in the control group (P < .05). There were six cases of absent end-diastolic flow (AED) in the FGR group. There were no statistically significant between-group differences in the Mod-MPI, isovolumetric contraction time (ICT), and ejection time (ET) (P > .05). There was also no statistically significant correlation between the Mod-MPI in the fetuses with AED and the control group for Mod-MPI (P > .05). CONCLUSION The utility of the Mod-MPI in FGR remains unclear. Future studies with larger populations are needed to determine the utility of the Mod-MPI as a predictor of cardiac compromise in FGR.
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Affiliation(s)
- Doğa Fatma Öcal
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Kadriye Yakut
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Filiz Halıcı Öztürk
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Merve Öztürk
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Yüksel Oğuz
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Orhan Altınboğa
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
| | - Şevki Çelen
- Dr. Zekai Tahir Burak Women Health Care Education and Research Hospital, Ankara, Turkey
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Alsolai AA, Bligh LN, Greer RM, Gooi A, Kumar S. Myocardial strain assessment using velocity vector imaging in normally grown fetuses at term. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:352-358. [PMID: 28608400 DOI: 10.1002/uog.17549] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/08/2017] [Accepted: 02/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess prospectively fetal myocardial deformation at term in normally grown fetuses using the velocity vector imaging (VVI) two-dimensional speckle-tracking technique, and to explore myocardial deformation changes over the last 4 weeks of pregnancy. METHODS This was a prospective, observational cohort study of 276 women with an uncomplicated singleton pregnancy who underwent fortnightly ultrasound from 36 weeks' gestation until delivery at the Mater Mother's Hospital, Brisbane, Australia. Fetal myocardial deformation (assessed by global and segmental longitudinal systolic myocardial strain and strain rate of both right and left ventricles) was measured using VVI software. RESULTS Mean global longitudinal left and right ventricular strain and strain rate values decreased between each time point. At 36, 38 and 40 weeks' gestation, left ventricular global strain (%) and strain rate (/s) decreased, respectively, as follows: -14.6 ± 3.8% and -1.2 ± 0.3/s at 36 weeks; -13.6 ± 3.3% and -1.1 ± 0.3/s at 38 weeks; and -12.3 ± 3.1% and -1.0 ± 0.3/s at 40 weeks. At 36, 38 and 40 weeks, mean right ventricular global strain (%) and mean strain rate (/s) decreased, respectively, as follows: -14.2 ± 3.4% and -1.2 ± 0.2/s at 36 weeks; -13.4 ± 3.0% and -1.1 ± 0.2/s at 38 weeks; and -12.8 ± 2.8% and -1.1 ± 0.2/s at 40 weeks. CONCLUSIONS Global ventricular strain values diminish with advancing gestational age. Myocardial deformation imaging is feasible in late gestation and may be useful as an adjunct for the assessment of fetal cardiac function close to birth. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A A Alsolai
- College of Applied Medical Science, King Saud University, Riyadh, Kingdom of Saudi Arabia
- School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - L N Bligh
- School of Biomedical Science, University of Queensland, St Lucia, Queensland, Australia
| | - R M Greer
- School of Medicine, University of Queensland, Herston, Queensland, Australia
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - A Gooi
- Mater Health Services, South Brisbane, Queensland, Australia
| | - S Kumar
- School of Medicine, University of Queensland, Herston, Queensland, Australia
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Mater Health Services, South Brisbane, Queensland, Australia
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The transverse four-chamber view for the assessment of atrial tissue deformation in the fetus. PLoS One 2018; 13:e0199581. [PMID: 29965971 PMCID: PMC6028085 DOI: 10.1371/journal.pone.0199581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/09/2018] [Indexed: 01/30/2023] Open
Abstract
AIMS To determine if atrial tissue deformation (peak strain, PS) and time to peak strain (TTPS) can be assessed in the fetus, with identification of best echocardiographic plane. MATERIALS AND METHODS Pulsed-wave tissue Doppler study of a longitudinal and a transverse four-chamber view (FCV) in each of 20 healthy fetuses. Determination of PS and TTPS in regions of interest (ROI), viz., lateral walls of the right and left atria (RA, LA); comparison of values depending on section plane, with results-based discussion of the physiology of fetal atrial deformation and of possible clinical uses. RESULTS PS and TTPS could be determined on transverse FCV in 91% of subjects and in 61% on longitudinal FCV. Transverse PS and TTPS were significantly higher than longitudinal (p = 0.0001). Transverse PS was significantly higher in RA than in LA (26.9% vs. 17.3%, p = 0.034), and transverse TTPS was significantly shorter in RA than in LA (p = 0.034). CONCLUSION Atrial radial PS and TTPS determinations are possible in the fetus. The transverse FCV is best suited for these. The highest PS values and shortest TTPS values are found in ROI representing the RA. Our findings may contribute to detailed intrauterine assessment of atrial and ventricular myocardial function.
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Graupner O, Enzensberger C, Wieg L, Wolter A, Yerebakan C, Khalil M, Axt-Fliedner R. Segmental Myocardial Displacement and Tissue Velocity Analysis of the Right Ventricle in Hypoplastic Left Heart Syndrome Fetuses and Controls Using Color Tissue Doppler Imaging (C-TDI). PRENATAL CARDIOLOGY 2017. [DOI: 10.1515/pcard-2017-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Introduction: The long-term outcome of patients with HLHS (hypoplastic left heart syndrome) is mainly determined by right ventricular function. Our study examines, whether there are differences in segmental right ventricular myocardial displacement and tissue velocities of fetuses with HLHS compared to healthy fetuses during gestation. Materials and methods: A prospective study was conducted including 20 fetuses with HLHS and 20 gestational age matched controls. c-TDI (colour tissue Doppler imaging) derived systolic and diastolic velocities as well as myocardial displacement were assessed in three different locations of the right ventricle (RV). A ROI (region of interest) was placed in the basal, middle and apical part of the myocardium. Possible changes of c-TDI indices in the course of pregnancy and between the three different segments were investigated in both groups. Results: HLHS fetuses showed significantly lower e' velocities measured in the basal and middle part of the RV compared to healthy controls (p < 0.05). Basal displacement showed significantly lower values in HLHS fetuses compared to controls. In control fetuses but not in HLHS fetuses there was a significant increase of basal diastolic velocities and displacement in the course of pregnancy. According to myocardial velocities and displacement values there was a significant decrease from the base of the fetal heart to the apex pointed in both groups. Conclusions: An altered right ventricular myocardial function in HLHS fetuses within different myocardial segments could be demonstrated. An apicobasal gradient with higher velocity and displacement values in the basal part of RV myocardium could be found in both groups. The technique may be of value in the prenatal assessment of myocardial function, however its role as a monitoring tool and outcome predictor needs to be defined.
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Affiliation(s)
- Oliver Graupner
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technical University of Munich, Munich , Germany
| | - Christian Enzensberger
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen , Germany
| | - Larissa Wieg
- Department of Cardiology, Klinikum rechts der Isar, Technical University of Munich, Munich , Germany
| | - Aline Wolter
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen , Germany
| | - Can Yerebakan
- NCardiovascular Surgery, Children’s National Heart Institute, George Washington University Medical Center, Washington , DC, USA
| | - Markus Khalil
- Department of Paediatric Cardiology, Justus-Liebig-University and UKGM, Giessen , Germany
| | - Roland Axt-Fliedner
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, Justus-Liebig-University and UKGM, Giessen , Germany
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Graupner O, Enzensberger C, Wieg L, Willruth A, Steinhard J, Gembruch U, Doelle A, Bahlmann F, Kawecki A, Degenhardt J, Wolter A, Herrmann J, Axt-Fliedner R. Evaluation of right ventricular function in fetal hypoplastic left heart syndrome by color tissue Doppler imaging. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:732-738. [PMID: 26138790 DOI: 10.1002/uog.14940] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 06/23/2015] [Accepted: 06/28/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Postnatal outcome of fetuses with hypoplastic left heart syndrome (HLHS) is determined mainly by right ventricular function. Our study examines whether there are differences in right ventricular function during gestation of fetuses with HLHS compared with healthy fetuses. METHODS A prospective study was conducted including 20 fetuses with HLHS and 20 gestational age-matched controls. Peak systolic and diastolic right ventricular free wall velocities were assessed using color tissue Doppler imaging (c-TDI). Subsequently, isovolumic time intervals, ejection time (ET'), E'/A' ratio and tissue Doppler-derived myocardial performance index (MPI') were calculated. Possible changes to c-TDI indices during the course of pregnancy in both the HLHS group and the control group were investigated. RESULTS Examination of right ventricular function revealed significantly lower E' velocities (13.6 vs 21.0 cm/s; P = 0.017) and E'/A' ratios (0.55 vs 0.76; P = 0.012) and prolonged isovolumic contraction time (ICT') (57.0 vs 45.7 ms; P = 0.008) in the HLHS group compared with healthy fetuses. Furthermore, isovolumic relaxation time and MPI' increased significantly with gestational age in HLHS fetuses but not in controls. Values for systolic and diastolic peak velocities (E', A', S'), ET' and ICT' did not change significantly during gestation in either group. CONCLUSION Right ventricular function in HLHS is altered as early as in fetal life, well before palliative surgery is performed. Future research should provide further insight into ventricular remodeling during gestation in cases of HLHS. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- O Graupner
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - C Enzensberger
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
| | - L Wieg
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
| | - A Willruth
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - J Steinhard
- Fetal Cardiology, Heart & Diabetes Center, Ruhr University Bochum, North-Rhine Westphalia, Bad Oeynhausen, Germany
| | - U Gembruch
- Department of Obstetrics and Gynecology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - A Doelle
- Toshiba Medical Systems, Neuss, Germany
| | - F Bahlmann
- Department of Obstetrics and Gynecology, Bürgerhospital, Frankfurt, Germany
| | - A Kawecki
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
| | - J Degenhardt
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
| | - A Wolter
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
| | - J Herrmann
- Statistical Consulting Gießen, Gießen, Germany
| | - R Axt-Fliedner
- Division of Perinatal Medicine, Department of Obstetrics & Gynecology, University Hospital Gießen and Marburg, Justus-Liebig University, Gießen, Germany
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Zhao Y, Abuhamad S, Sinkovskaya E, Mlynarczyk M, Romary L, Abuhamad A. Cardiac axis shift within the cardiac cycle of normal fetuses and fetuses with congenital heart defect. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:558-563. [PMID: 25511021 DOI: 10.1002/uog.14768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 11/24/2014] [Accepted: 12/08/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To investigate changes in the cardiac axis (CAx) within the cardiac cycle of normal fetuses and fetuses with congenital heart defects (CHD). METHODS This was a retrospective case-control study in which stored videoclips of four-chamber views from 527 prenatal ultrasound examinations performed at 18 + 0 to 36 + 6 weeks of gestation were reviewed. Among the ultrasound scans included, 287 were of normal fetuses (controls) and 240 were of fetuses with CHD. In each case, the CAx was measured at end systole (just before the atrioventricular (AV) valve opened) and at end diastole (just before the AV valve closed). CAx measurements of fetuses with CHD were compared to those of controls. RESULTS The mean CAx in the control group was 45.9 ± 8.5° at end systole and 38.3 ± 8.4° at end diastole (P < 0.001), resulting in an average difference of 7.6 ± 3.2°. The mean CAx in fetuses with CHD was 53.4 ± 17.8° at end systole and 47.5 ± 17.3° at end diastole (P < 0.001), resulting in an average difference of 5.9 ± 6.3°. However, in some forms of CHD, such as hypoplastic left heart syndrome and L-transposition of the great arteries, the CAx was greater at end diastole than at end systole, with a difference of more than 5°. In 21.3% of control fetuses, there was a CAx shift within the cardiac cycle of ≥ 10°. Abnormal CAx measured at end systole was strongly associated with CHD. CONCLUSIONS Measurement of the CAx at end systole provides values that differ from those when measured at end diastole, in both normal fetuses and those with CHD. We recommend that the CAx be measured at end systole as a greater proportion of fetuses with CHD and fewer normal fetuses have an abnormal CAx at this stage compared to at end diastole. The occurrence of an abnormal CAx and the CAx shift within the fetal cardiac cycle depend on the type of CHD.
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Affiliation(s)
- Y Zhao
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - S Abuhamad
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - E Sinkovskaya
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - M Mlynarczyk
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - L Romary
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - A Abuhamad
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
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Mahajan A, Henry A, Meriki N, Hernandez-Andrade E, Crispi F, Wu L, Welsh AW. The (Pulsed-Wave) Doppler Fetal Myocardial Performance Index: Technical Challenges, Clinical Applications and Future Research. Fetal Diagn Ther 2015; 38:1-13. [DOI: 10.1159/000363181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/24/2014] [Indexed: 11/19/2022]
Abstract
Functional cardiovascular assessment is becoming an increasingly important tool in the study of fetal pathology. The myocardial performance index (MPI) is a parameter measuring global myocardial function. Since its introduction, several studies have proposed methods to improve its reproducibility and have constructed normative reference ranges. Fetal heart evaluation using the MPI is technically challenging, requiring specific training and expertise, and a consensus has yet to be reached on the method of delineating the time periods used to calculate the index. Despite these limitations, it has been shown to be a useful and highly sensitive parameter of dysfunction in a number of fetal pathologies. Further research is warranted into the effect of pathology on MPI, parameters of unilateral cardiac strain that utilise MPI, and automation of the MPI to encourage incorporation of the MPI as a useful tool in clinical practice.
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Aye C, Davis E, Upton R, Lewandowski AJ, Leeson P. Assessment of cardiac function from fetal to adult life with myocardial deformation imaging. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:605-608. [PMID: 24888740 DOI: 10.1002/uog.13397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- C Aye
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, OX39DU, UK; Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
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Saini AP, Ural S, Pauliks LB. Quantitation of Fetal Heart Function With Tissue Doppler Velocity Imaging-Reference Values for Color Tissue Doppler Velocities and Comparison With Pulsed Wave Tissue Doppler Velocities. Artif Organs 2013; 38:87-91. [DOI: 10.1111/aor.12187] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ashish P. Saini
- Department of Pediatrics; Division of Pediatric Cardiology; Penn State Hershey College of Medicine; Hershey PA USA
| | - Serdar Ural
- Department of Obstetrics and Gynecology; Division of Maternal Fetal Medicine; Penn State Hershey College of Medicine; Hershey PA USA
| | - Linda B. Pauliks
- Department of Pediatrics; Division of Pediatric Cardiology; Penn State Hershey College of Medicine; Hershey PA USA
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Wågström E, Johnson J, Ferm-Widlund K, Elmstedt N, Liuba K, Lind B, Brodin LÅ, Lundbäck S, Westgren M. The cardiac state diagram as a novel approach for the evaluation of pre- and post-ejection phases of the cardiac cycle in asphyxiated fetal lambs. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1682-1687. [PMID: 23849391 DOI: 10.1016/j.ultrasmedbio.2013.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Revised: 04/08/2013] [Accepted: 04/11/2013] [Indexed: 06/02/2023]
Abstract
The aim of this study was to investigate myocardial wall motion using echocardiography and color-coded tissue velocity imaging and to generate a cardiac state diagram for evaluation of the duration of the pre- and post-ejection phases in asphyxiated fetal lambs. Six near-term lambs were partly exteriorized and brought to cardiac arrest through asphyxia. Echocardiography measurements were recorded simultaneously with arterial blood sampling for lactate and blood gases. All fetal lambs exhibited prolongation of the pre- and post-ejection phases at the time when the most pronounced changes in lactate concentration and pH occurred. The mean change in duration of the pre- and post-ejection phases for all fetal lambs was 36 ± 7 ms (p < 0.002) and 77 ± 17 ms (p < 0.019), respectively, and the percentage change was 50% (p < 0.001) and 38% (p < 0.049), respectively. As asphyxia progressed in fetal lambs, the duration of the pre- and post-ejection phases increased. The cardiac state diagram has the potential to be a comprehensible tool for detecting fetal asphyxia.
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Affiliation(s)
- Elle Wågström
- Department of Obstetrics and Gynecology, Center of Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden.
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12
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Elmstedt NN, Johnson JJ, Lind BB, Ferm-Widlund KK, Herling LL, Westgren MM, Brodin LÅL. Reference values for fetal tissue velocity imaging and a new approach to evaluate fetal myocardial function. Cardiovasc Ultrasound 2013; 11:29. [PMID: 23947791 PMCID: PMC3751897 DOI: 10.1186/1476-7120-11-29] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 08/09/2013] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Myocardial function can be evaluated using color-coded tissue velocity imaging (TVI) to analyze the longitudinal myocardial velocity profile, and by expressing the motion of the atrioventricular plane during a cardiac cycle as coordinated events in the cardiac state diagram (CSD). The objective of this study was to establish gestational age specific reference values for fetal TVI measurements and to introduce the CSD as a potential aid in fetal myocardial evaluation. METHODS TVI recordings from 125 healthy fetuses, at 18 to 42 weeks of gestation, were performed with the transducer perpendicular to the apex to provide a four-chamber view. The myocardial velocity data was extracted from the basal segment of septum as well as the left and right ventricular free wall for subsequent offline analysis. RESULTS During a cardiac cycle the longitudinal peak velocities of septum increased with gestational age, as did the peak velocities of the left and right ventricular free wall, except for the peak velocity of post ejection. The duration of rapid filling and atrial contraction increased during pregnancy while the duration of post ejection decreased. The duration of pre ejection and ventricular ejection did not change significantly with gestational age. CONCLUSION Evaluating fetal systolic and diastolic performance using TVI together with CSD could contribute to increase the knowledge and understanding of fetal myocardial function and dysfunction. The pre and post ejection phases are the variables most likely to indicate fetuses with abnormal myocardial function.
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13
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Germanakis I, Matsui H, Gardiner HM. Myocardial Strain Abnormalities in Fetal Congenital Heart Disease Assessed by Speckle Tracking Echocardiography. Fetal Diagn Ther 2012; 32:123-30. [DOI: 10.1159/000334413] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 10/11/2011] [Indexed: 11/19/2022]
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14
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Germanakis I, Gardiner H. Assessment of Fetal Myocardial Deformation Using Speckle Tracking Techniques. Fetal Diagn Ther 2012; 32:39-46. [DOI: 10.1159/000330378] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 06/07/2011] [Indexed: 11/19/2022]
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Crispi F, Gratacós E. Fetal cardiac function: technical considerations and potential research and clinical applications. Fetal Diagn Ther 2012; 32:47-64. [PMID: 22614129 DOI: 10.1159/000338003] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 03/07/2012] [Indexed: 12/12/2022]
Abstract
Fetal echocardiography was initially used to detect structural anomalies but has more recently also been proposed to assess fetal cardiac function. This review summarizes technical issues and limitations in fetal cardiac function evaluation, as well as its potential research and clinical applications. Functional echocardiography has been demonstrated to select high-risk populations and to be associated with outcome in several fetal conditions including intrauterine growth restriction, twin-to-twin transfusion syndrome, maternal diabetes, and congenital diaphragmatic hernia. Fetal heart evaluation is challenging due to the smallness and high heart rate of the fetus and restricted access to the fetus far from the transducer. Due to these limitations and differences in cardiac function which are related to fetal maturation, cardiovascular parameters should be validated in the fetus and used with caution. Despite these precautions, in expert hands and with appropriate ultrasound equipment, evaluation of cardiac function is feasible in most fetuses. Functional fetal echocardiography is a promising tool that may soon be incorporated into clinical practice. Research is warranted to further refine the contribution of fetal cardiac assessment to the diagnosis, monitoring, or prediction of outcomes in various fetal conditions.
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Affiliation(s)
- Fatima Crispi
- Department of Maternal-Fetal Medicine, Institut Clínic de Ginecologia, Obstetrícia i Neonatologia, Hospital Clinic - Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
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Elmstedt N, Ferm-Widlund K, Lind B, Brodin LÅ, Westgren M. Fetal cardiac muscle contractility decreases with gestational age: a color-coded tissue velocity imaging study. Cardiovasc Ultrasound 2012; 10:19. [PMID: 22571652 PMCID: PMC3403944 DOI: 10.1186/1476-7120-10-19] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 05/09/2012] [Indexed: 11/13/2022] Open
Abstract
Background Present data regarding how the fetal heart works and develops throughout gestation is limited. However, the possibility to analyze the myocardial velocity profile provides new possibilities to gain further knowledge in this area. Thus, the objective of this study was to evaluate human fetal myocardial characteristics and deformation properties using color-coded tissue velocity imaging (TVI). Methods TVI recordings from 55 healthy fetuses, at 18 to 42 weeks of gestation, were acquired at a frame rate of 201–273 frames/s for offline analysis using software enabling retrieval of the myocardial velocity curve and 2D anatomical information. The measurements were taken from an apical four-chamber view, and the acquired data was correlated using regression analysis. Results Left ventricular length and width increased uniformly with gestational age. Atrioventricular plane displacement and the E’/A’ ratio also increased with gestational age, while a longitudinal shortening was demonstrated. Conclusions Fetal cardiac muscle contractility decreases with gestational age. As numerous fetal- and pregnancy-associated conditions directly influence the pumping function of the fetal heart, we believe that this new insight into the physiology of the human fetal cardiovascular system could contribute to make diagnosis and risk assessment easier and more accurate.
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Affiliation(s)
- Nina Elmstedt
- Department of Medical Engineering, School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden.
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Germanakis I, Pepes S, Sifakis S, Gardiner H. Fetal Longitudinal Myocardial Function Assessment by Anatomic M-Mode. Fetal Diagn Ther 2012; 32:65-71. [DOI: 10.1159/000330790] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 07/06/2011] [Indexed: 11/19/2022]
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Crispi F, Sepulveda-Swatson E, Cruz-Lemini M, Rojas-Benavente J, Garcia-Posada R, Dominguez JM, Sitges M, Bijnens B, Gratacós E. Feasibility and Reproducibility of a Standard Protocol for 2D Speckle Tracking and Tissue Doppler-Based Strain and Strain Rate Analysis of the Fetal Heart. Fetal Diagn Ther 2012; 32:96-108. [DOI: 10.1159/000337329] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2011] [Accepted: 02/09/2012] [Indexed: 11/19/2022]
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Comas M, Crispi F. Assessment of Fetal Cardiac Function Using Tissue Doppler Techniques. Fetal Diagn Ther 2012; 32:30-8. [DOI: 10.1159/000335028] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 11/02/2011] [Indexed: 11/19/2022]
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Elmstedt N, Lind B, Ferm-Widlund K, Westgren M, Brodin LÅ. Temporal frequency requirements for tissue velocity imaging of the fetal heart. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:413-417. [PMID: 21936002 DOI: 10.1002/uog.8872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The high velocity and short duration of myocardial motion requires a high sampling rate to obtain adequate temporal resolution; this issue becomes even more important when taking into consideration the high fetal heart rate. In this study we have established optimal sampling requirements for assessing the duration of various cardiac cycle events and myocardial velocities of the fetal heart using color-coded tissue velocity imaging (TVI). METHODS Recordings from 30 fetuses were acquired at an initial frame rate of 180-273 frames/s. All TVI recordings were performed from an apical four-chamber view and stored as cineloops of five to 10 consecutive cardiac cycles for subsequent offline analysis using software enabling a reduction in frame rate. Different components of the myocardial velocity curve, obtained from the basal part of the ventricular septum, were measured at the initial frame rate and compared with their equivalents at gradually decreased frame rates. RESULTS As acquisition frame rate was reduced, there was a marked increase in deviation from the initial values, resulting in an underestimation of all systolic and diastolic velocities. For the measured durations, there was a clear tendency to underestimate isovolumetric contraction and relaxation, and a clear tendency to overestimate ventricular ejection and diastolic E-wave and A-wave. An acceptable ⩽ 5% deviation from the value obtained at the highest frame rate corresponded to measurements obtained at above 150-200 frames/s. CONCLUSIONS A high sampling rate of at least 200 frames/s is necessary for adequate reconstruction of TVI data for the fetal heart. Frame rates that are too low result in considerable loss of temporal and velocity information.
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Affiliation(s)
- N Elmstedt
- Department of Medical Engineering, School of Technology and Health, Royal Institute of Technology, Stockholm, Sweden.
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Tutschek B, Schmidt KG. Pulsed-wave tissue Doppler echocardiography for the analysis of fetal cardiac arrhythmias. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 38:406-412. [PMID: 21656866 DOI: 10.1002/uog.9070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Rhythm analysis of the fetal heart is hampered by the inability to routinely obtain electrocardiographic recordings of the fetus. Doppler studies of fetal cardiac tissue movements, assessing cardiac movements both qualitatively and quantitatively, have recently been described. We used a conventional high-resolution ultrasound system to obtain rhythm data from pulsed-wave tissue Doppler signals of the fetal heart in normal cardiac rhythm and in a variety of fetal cardiac arrhythmias. METHODS Fifty-five fetuses with normal (sinus) rhythm, 45 fetuses with rhythm disturbances and two neonates (one with arrhythmia and one with normal sinus rhythm) were studied. Using a conventional high-resolution ultrasound system equipped for fetal studies, but without specific tissue Doppler hardware or software, we performed pulsed-wave tissue Doppler echocardiography (PW-TDE) of atrioventricular valve ring excursions to study the atrial and ventricular mechanical actions. In the neonates, electrocardiograms were also recorded. RESULTS PW-TDE in normal fetuses shows a typical pattern of tissue motion parallel to the long axis of the heart and in the opposite direction to the blood flow, both in systole and diastole. This pattern is easily obtained from the tricuspid valve annulus in normal sinus rhythm and shows characteristic changes in various fetal arrhythmias. CONCLUSION PW-TDE of atrioventricular valve annulus movement patterns may prove to be a valuable additional tool for assessing fetal cardiac arrhythmias.
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Affiliation(s)
- B Tutschek
- Department of Obstetrics and Gynecology, Bern University Hospital, Bern, Switzerland; Medical Faculty, Heinrich Heine University, Düsseldorf, Germany.
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Matsui H, Germanakis I, Kulinskaya E, Gardiner HM. Temporal and spatial performance of vector velocity imaging in the human fetal heart. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2011; 37:150-157. [PMID: 20814875 DOI: 10.1002/uog.8815] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVES To assess the spatial and temporal performance of fetal myocardial speckle tracking, using high-frame-rate (HFR) storing and Lagrangian strain analysis. METHODS Dummy electrocardiographic signaling permitted DICOM HFR in 124 normal fetuses and paired low-frame-rate (LFR) video storing at 25 Hz in 93 of them. Vector velocity imaging (VVI) tracking co-ordinates were used to compare time and spatial domain measures. We compared tracking success, Lagrangian strain, peak diastolic velocity and positive strain rate values in HFR vs. LFR video storing. Further comparisons within an HFR subset included Lagrangian vs. natural strain, VVI vs. M-mode annular displacement, and VVI vs. pulsed-wave tissue Doppler imaging (TDI) peak velocities. RESULTS HFR (average 79.4 Hz) tracking was more successful than LFR (86 vs. 76%, P = 0.024). Lagrangian and natural HFR strain correlated highly (left ventricle (LV): r = 0.883, P < 0.001; right ventricle (RV): r = 0.792, P < 0.001) but natural strain gave 20% lower values, suggesting reduced reliability of measurement. Lagrangian HFR strain was similar in LV and RV and decreased with gestation (P = 0.015 and P < 0.001, respectively). LV Lagrangian LFR strain was significantly lower than the values for the RV (P < 0.001) and those using paired LV-HFR recordings (P = 0.007). Annular displacement methods correlated highly (LV = 1.046, r = 0.90, P < 0.001; RV = 1.170, r = 0.88, P < 0.001). Early diastolic waves were visible in 95% of TDI, but in only 26% of HFR and 0% of LFR recordings, and HFR-VVI velocities were significantly lower than those for TDI (P < 0.001). CONCLUSIONS Doppler estimation of velocities remains superior to VVI but image gating and use of original co-ordinates should improve offline VVI assessment of fetal myocardial function.
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Affiliation(s)
- H Matsui
- Department of Reproductive Biology, Imperial College at Queen Charlotte's and Chelsea Hospital, London, UK
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Tutschek B, Schmidt KG. Techniques for assessing cardiac output and fetal cardiac function. Semin Fetal Neonatal Med 2011; 16:13-21. [PMID: 21051302 DOI: 10.1016/j.siny.2010.09.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fetal echocardiography was initially used to diagnose structural heart disease, but recent interest has focused on functional assessment. Effects of extracardiac conditions on the cardiac function such as volume overload (in the recipient in twin-twin transfusion syndrome), a hyperdynamic circulation (arterio-venous malformation), cardiac compression (diaphragmatic hernia, lung tumours) and increased placental resistance (intrauterine growth restriction and placental insufficiency) can be studied by ultrasound and may guide decisions for intervention or delivery. A variety of functional tests can be used, but there is no single clinical standard. For some specific conditions, however, certain tests have shown diagnostic value.
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Affiliation(s)
- Boris Tutschek
- Department of Obstetrics, Bern University Hospital, Effingerstrasse 102, 3010 Bern, Switzerland.
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AIUM practice guideline for the performance of fetal echocardiography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:127-136. [PMID: 21193716 DOI: 10.7863/jum.2011.30.1.127] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Myocardial dysfunction in fetuses exposed to intraamniotic infection: new insights from tissue Doppler and strain imaging. Am J Obstet Gynecol 2010; 203:459.e1-7. [PMID: 20691411 DOI: 10.1016/j.ajog.2010.06.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/02/2010] [Accepted: 06/15/2010] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The purpose of this study was to assess myocardial function of fetuses who were exposed to intraamniotic infection compared with fetuses of uncomplicated pregnancies by the application of tissue Doppler and strain rate (SR) imaging. STUDY DESIGN We evaluated the right ventricular function of fetuses with preterm premature rupture of membranes and proven intraamniotic infection (n = 12 fetuses) and healthy fetuses (n = 27). Tissue Doppler velocities during early diastolic relaxation (E(m)) and atrial contraction (A(m)) and early diastolic SR were measured as indices of diastolic function, whereas the peak systolic strain and SR were used as parameters of systolic function. RESULTS Fetuses with intraamniotic infection exhibit impairment in both diastolic and systolic performance, which was characterized by increased diastolic compliance (increased E(m)/A(m) ratio, increased early diastolic SR compared with the control fetuses), decreased systolic contractile function (reduced systolic strain and SR), and longitudinal myocardial dyskinesia. CONCLUSION New echocardiographic tools suggest that fetal heart is a target organ in the context of intraamniotic infection.
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Van Mieghem T, DeKoninck P, Steenhaut P, Deprest J. Methods for prenatal assessment of fetal cardiac function. Prenat Diagn 2009; 29:1193-203. [DOI: 10.1002/pd.2379] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Larsen LU, Sloth E, Petersen OB, Pedersen TF, Sorensen K, Uldbjerg N. Systolic myocardial velocity alterations in the growth-restricted fetus with cerebroplacental redistribution. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2009; 34:62-67. [PMID: 19489024 DOI: 10.1002/uog.6375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Intrauterine growth restriction (IUGR) is associated with cerebroplacental redistribution (CPR), fetal stress and poor outcome, all of which may be related to dysfunction of the fetal myocardium. The aim of this study was to specifically assess myocardial function in IUGR fetuses with CPR in comparison with normal fetuses using color Doppler myocardial imaging (CDMI). METHODS CDMI was used to evaluate and compare myocardial velocities in the left and right ventricles in normal fetuses and in IUGR fetuses with CPR. Peak systolic tissue velocities (S') were acquired from both ventricular free walls in 20 IUGR fetuses (gestational age at scan ranged from 26 + 1 to 34 + 6 weeks, with serial measurements obtained in nine) and 42 normal fetuses (35 at week 28, with the remaining seven undergoing serial scans every 4 weeks, ranging from 18 + 6 to 39 + 1 weeks). Umbilical artery (UA), middle cerebral artery (MCA) and ductus venosus (DV) flows were also recorded. RESULTS Left and right S' increased with gestational age in normal pregnancy. Fetuses with IUGR and CPR had lower left ventricular S' than normal fetuses (mean, 2.41 (95% CI, 1.96-2.86) cm/s vs. 3.30 (95% CI, 3.05-3.55) cm/s; P = 0.0006). This reduction in S' correlated with the grade of UA flow abnormality (P = 0.0002). Fetuses with reversed diastolic UA flow had significantly lower left S' (mean, 2.0 (95% CI, 1.4-2.6) cm/s; P = 0.001) than normal fetuses. There was no correlation between left S' and MCA pulsatility index (P = 0.37) in the IUGR-CPR group, but there was a reduction in S' approaching statistical significance in fetuses with reversed DV flow in comparison to those without it (P = 0.09). Right S' was similar in the two study groups and did not correlate with worsening UA flow class. All fetuses with a left S' below 1.6 cm/s and reversed UA flow died in the perinatal period. CONCLUSIONS CDMI facilitates acquisition of fetal myocardial ventricular S'. The combination of IUGR and CPR is associated with a reduced left ventricular S', especially in those with reversed UA flow. In this subgroup a left S' below 1.6 cm/s seemed to predict mortality in the perinatal period.
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Affiliation(s)
- L U Larsen
- Department of Obstetrics and Gynecology, Aarhus University Hospital Skejby, Aarhus, Denmark.
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Barker PC, Houle H, Li JS, Miller S, Herlong JR, Camitta MG. Global Longitudinal Cardiac Strain and Strain Rate for Assessment of Fetal Cardiac Function: Novel Experience with Velocity Vector Imaging. Echocardiography 2009; 26:28-36. [DOI: 10.1111/j.1540-8175.2008.00761.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Lee W, Allan L, Carvalho JS, Chaoui R, Copel J, Devore G, Hecher K, Munoz H, Nelson T, Paladini D, Yagel S. ISUOG consensus statement: what constitutes a fetal echocardiogram? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:239-242. [PMID: 18663769 DOI: 10.1002/uog.6115] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- W Lee
- Division of Fetal Imaging, William Beaumont Hospital, 3601 West Thirteen Mile Road, Royal Oak, Michigan 48073, USA.
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Bibliography. Current world literature. Maternal-fetal medicine. Curr Opin Obstet Gynecol 2007; 19:196-201. [PMID: 17353689 DOI: 10.1097/gco.0b013e32812142e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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