Brazilian Fetal Cardiology Guidelines - 2019

Epicardial pacing lead implantation for congenital complete atrioventricular block immediately after birth: a case report

BACKGROUND

The incidence of congenital complete atrioventricular block is estimated to be 1 per 20,000 deliveries. In the fetal period, the fetal mortality rate is high, but the treatment strategy has not yet been established. In severe cases, early postnatal pacing therapy is necessary.

CASE PRESENTATION

A 0-day-old Japanese baby girl was diagnosed with fetal congenital complete atrioventricular block during a prenatal physical examination. A joint conference was held preoperatively among multidisciplinary departments, and a cesarean section was performed at 37 weeks pregnancy, immediately followed by scheduled internal ventricular pacing lead implantation in an adjacent room. Percutaneous pacing was ineffective. The epicardial pacing lead was sutured at 17.5 minutes after birth, and perioperative management was successful with a heart rate and pulse rate of 150 beats per minute.

CONCLUSION

The infant with a congenital complete atrioventricular block was rescued by an uneventful epicardial lead implantation.

Assessment of fetal heart aortic and pulmonary valve annulus area by three-dimensional ultrasonography: reference curves and applicability in congenital heart diseases

OBJECTIVES

To determine reference curves for fetal aortic and pulmonary valve annulus area by three-dimensional ultrasonography using the spatio-temporal image correlation (STIC) in the rendering mode, and to ascertain its applicability in congenital heart disease (CHD).

METHODS

We performed a retrospective cross-sectional study of 328 normal fetuses and 42 fetuses with CHD between 20 and 33 weeks 6 days of gestation. The outflow plane view of the great vessels was used to measure the areas of the valvar annuli, and the measurements were performed in systole. A linear regression model adjusted according to the determination coefficient (R²) was utilized to construct the reference intervals. The concordance correlation coefficient (CCC) was used to calculate the reproducibility of the mitral and tricuspid valve areas.

RESULTS

The mean ± standard deviation (SD) of the aortic and pulmonary valve annulus areas ranged from 6.6 ± 1.2 to 32.9 ± 1.1 mm² and 10.7 ± 1.3 to 40.3 ± 1.2 mm², respectively. We observed a linear relationship and strong positive correlation between the area of the aortic and pulmonary valve annuli with r=0.97 and 0.96, respectively. Good intra (CCC=0.99) and interobserver agreement (CCC=0.98) was observed for the measurement of the aortic valve annulus area. A good intra (CCC=0.99) and interobserver (CCC=0.97) agreement was also observed for the measurement of the pulmonary valve annulus area. The mean ± SD of the difference of the areas of the aortic and pulmonary valve annuli between the normal fetuses and those with CHD were -1.801 ± 1.429 mm² (p=0.208) and -1.033 ± 1.467 mm² (p<0.0001), respectively.

CONCLUSIONS

The reference curves for the areas of the aortic and pulmonary valve annuli of fetal hearts were determined, and showed good inter and intraobserver reproducibility. The constructed reference curves showed applicability in different types of CHD.

Cardiac Function Assessment in Fetuses With Ductus Arteriosus Constriction: A Two-Dimensional Echocardiography and FetalHQ Study

Background

Fetal ductal constriction (DC) is associated with excessive polyphenol-rich food (PRF) consumption during pregnancy. However, the effect of this hemodynamic change on fetal cardiac function still needs to be elucidated. Therefore, this study aimed to evaluate the cardiac function of fetuses with PRF-related DC and to describe serial observations of cardiac function changes.

Methods

We compared the traditional echocardiographic indices, including morphological, hemodynamic, and functional parameters, between study fetuses and controls. For global and segmental deformation analysis of the left and right ventricles, fetalHQ with the speckle-tracking technique was used to calculate sphericity index (SI), global longitudinal strain (GLS), fractional shortening (FS), fractional area change (FAC), etc. In addition, follow-up data were compared with the generalized linear model.

Results

A total of 60 DC fetuses and 60 gestational-matched controls were enrolled in our study, with 20 DC fetuses undertaking a follow-up echocardiogram after 2–3 weeks. Compared with controls, there was a distinct decrease in right ventricular GLS (RVGLS) (−13.39 ± 3.77 vs. −21.59 ± 2.51, p &lt; 0.001), RVFAC (22.20 ± 9.56 vs. 36.01 ± 4.84, p &lt; 0.001), left ventricular GLS (LVGLS) (−19.52 ± 3.24 vs. −23.81 ± 2.01 p &lt; 0.001), and LVFAC (39.64 ± 7.32 vs. 44.89 ± 4.91, p = 0.004). For 24-segment FS analysis, DC fetuses showed lower FS in left ventricular (LV) segments 18–24, with no difference in LV segments 1–17. Right ventricular (RV) FS in segments 4–23 was also reduced in the DC group. The 24-segment SI analysis indicated significantly lower SI in DC than those in controls for LV segments 1–14 and RV segments 19–24. We found that the pulsatility index (PI) of ductus arteriosus (DA) was an independent variable for RVGLS (β = −0.29, p = 0.04). In 20 DC fetuses with follow-up echocardiograms, no obvious difference in myocardial deformation was found between the initial examination and follow-up data.

Conclusion

Left and right ventricular performances were both impaired in DC fetuses, along with a series of morphological and hemodynamic changes. Although the state of DA constriction improved on second examinations, cardiac function was not completely restored.

Premature fetal closure of the ductus arteriosus of unknown cause – could it be influenced by maternal consumption of large quantities of herbal chamomile tea – a case report?

Objectives

The aim of this article was to present a case of premature fetal closure of the ductus arteriosus (DA) of unknown cause.

Case presentation

A 32-year-old pregnant woman came for the regular prenatal visit at 36 + 1 weeks of gestation (WG) at which oligohydramnios and premature closure of DA were revealed. Use of non-steroidal anti-inflammatory drugs was excluded by the history, although the patient had the symptoms of common cold 2 weeks before the check-up taking more than 1,000 mL of strong chamomile tea daily till the day before the prenatal visit. The patient was hospitalized at 36 + 1 weeks of gestation due to premature closure of DA and oligohydramnios (amniotic fluid index = 4.5/3), which was the indication to deliver the baby by cesarean section at 36 + 6 WG (birth weight was 2,830 g, birth length 49 cm and head circumference 34 cm, Apgar score at 1 and 5 min were 9/9). Postnatal course was uneventful, and postnatal echocardiography at 12 h of life revealed functionally closed DA and mild dysfunction of the right ventricle, which completely resolved after 7 days. The mother and the baby were discharged home healthy, and were doing well 3 months after delivery.

Conclusions

Although the cause of premature closure of DA in most of the cases will remain undetected, thorough history sometimes with unexpected events should be taken under the consideration as possible causative factor for premature DA closure, as was drinking of high quantities of chamomile tea in our case.

Reference values for left and right ventricular systolic-to-diastolic duration ratio (SDR) found using both spectral and tissue Doppler of fetal heart between 20 and 36+6 weeks of gestation

PURPOSE

To establish reference values for the systolic-to-diastolic duration ratio (SDR) of the left ventricle (LV) using spectral Doppler, as well as for the SDR' of the interventricular septum (SEP), LV, and right ventricles (RV) using tissue Doppler of the fetal heart.

METHOD

This prospective and cross-sectional study evaluated 374 low-risk singleton pregnancies from 20 to 36 + 6 weeks of gestation. The ventricular filling time (FT) was obtained from LV inflow using spectral Doppler. Tissue Doppler was used to assess the FT of each ventricle by placing the cursor at the atrioventricular junction marked by the mitral and tricuspid valves, respectively. SDR was calculated as the sum of the isovolumic contraction time (ICT) and the ejection time (ET) divided by the sum of the isovolumic relaxation time (IRT) and the ventricular FT. We used regression analysis to obtain the best-fit model polynomial equation for the parameters. The concordance correlation coefficient (CCC) was used to assess intra- and inter-observer reproducibility.

RESULTS

SDR and SDR' LV showed a progressive decrease with gestational age (GA); the SDR' RV and SDR' SEP did not show a significant decrease with advancing GA. The SDR LV (r = 0.29, p < 0.0001), SDR' RV (r = 0.21, p < 0.0001), SDR' LV (r = 0.20, p = 0.0001), and SDR' SEP (r = 0.25, p < 0.0001) showed a significant weak positive correlation with fetal heart rate. The inter-observer SDR' SEP measurements demonstrated poor reproducibility (CCC: 0.50), whereas intra-observer SRD LV measurements demonstrated moderate reproducibility (CCC: 0.78).

CONCLUSIONS

Reference values for SDR SEP, LV, and RV using spectral and tissue Doppler of fetal heart were established between 20 and 36+6 weeks of gestation.

Fetal Echocardiography Indications and Lack of Association between Abnormal Exams and Advanced Maternal Age: A Cross-Sectional Study - Fetal Abnormal Echocardiography

OBJECTIVE

 To analyze the most frequent referrals for fetal echocardiography, including advanced maternal age and its association with abnormal results.

METHODS

 We included all pregnant women referred to perform fetal echocardiography (gestational age 22-32 weeks) in 2 health centers in Rio de Janeiro, from June 2015 to June 2016. Advanced maternal age was considered when age was > 35 years at the time of delivery). Referral reasons and results were recorded, according to the Brazilian Fetal Cardiology Statement. Crude and adjusted prevalence ratios were calculated (Poisson regression). We considered p < 0.05 as significant.

RESULTS

 A total of 1,221 tests were analyzed. Abnormal fetal echocardiography was observed in 14.82% of the cases. The most frequent abnormalities were interventricular septal defect (6.39%), septal hypertrophy (3.35%) and atrioventricular septal defect (1.14%). Routine exams were performed in 559 women, 289 were referred for advanced maternal age and 373 were referred according to the Brazilian Fetal Cardiology Statement criteria. An obstetric ultrasound suggesting fetal cardiac abnormality, maternal diabetes, increased nuchal translucency, and obstetric ultrasound suggesting a noncardiac abnormality were strongly associated with an abnormal fetal echocardiography. Abnormal results were not more frequent in women with advanced maternal age when compared with the rest of the study group.

CONCLUSIONS

 It was observed that routine exams and advanced maternal age referrals were very frequent. Those exams were not associated to fetal echocardiography abnormalities. In this scenario, when the obstetric ultrasound suggests a fetal cardiac abnormality, the fetal echocardiography probably is abnormal. Therefore, obstetric ultrasound is a good screening method.