Left ventricular midwall mechanics at 24 weeks' gestation in high-risk normotensive pregnant women: Relationship to placenta-related complications of pregnancy

Most studies during pregnancy have assessed maternal left ventricular (LV) function by load-dependent indices, assessing only chamber function. The aim of this study was to assess afterload-adjusted LV myocardial and chamber systolic function at 24 weeks' gestation and 6 months postpartum in high-risk normotensive pregnant women

Comprehensive evaluation and comparison of different modalities for assessing fetal cardiac function

Fetal cardiac function analysis may provide crucial pathophysiological insights into fetal hemodynamic status, clarify cardiovascular adaptation to perinatal complications and improve clinical diagnosis and management of complicated pregnancies. A broad range of ultrasound techniques aim to predict cardiac dysfunction before there are clinical signs of fetal distress to allow early intervention. This thesis aimed to assess Pulsed-Wave Myocardial Performing Index (PW-MPI), Tissue Doppler Imaging MPI (TDI-MPI) and Tricuspid and Mitral Annular Plane Systolic Excursion (TAPSE and MAPSE) for evaluating fetal cardiac function. This was performed in several aspects: TDI has been proposed to be robust for detecting subclinical cardiac dysfunction over conventional Doppler. We found (79 cases) similar achievability and reproducibility, yet a poor correlation between TDI- and PW-MPI. Most probably due to considerably variable TDI waveform quality. This raised concerns about the technique for TDI-MPI. Online international study aiming to evaluate TDI-MPI demarcation and reliability. We compared annotations of 4 international experts (120 images) and found very high intra-observer repeatability, lower inter-observer reproducibility and variability in landmark definition, questioning the reliability of TDI-MPI. Evaluation of STIC M-mode for measuring TAPSE and MAPSE (102 cases). We found high achievability, high intra-observer repeatability for both sides and higher inter-observer reproducibility for TAPSE compared to MAPSE. We concluded that STIC allows easy and accessible evaluation of systolic function, that is reliable and repeatable, more so for TAPSE than MAPSE. Multimodality, global evaluation, which included a comparison of all modalities in 79 normal pregnancies, and in 30 scans from pregnancies complicated with IUGR or monochorionic twins. Achievability rates were high for all modalities. No single method was superior for both sides, TAPSE was more suited to the right heart and automated PWD-MPI for the left. These reflect each modality's specific qualities that accommodate best to the different structure and function of each heart side. This provides a useful first step for developing a clinical multimodality global scoring system that integrates the most favourable imaging technique for each side of the heart to optimally quantify the global heart function. This thesis also provides a firm basis for further research in this field

Longitudinal Behavior of Left-Ventricular Strain in Fetal Growth Restriction

Fetal growth restriction (FGR) is associated with an increased risk of adverse outcomes resulting from adaptive cardiovascular changes in conditions of placental insufficiency, leading to cardiac deformation and dysfunction, which can be evaluated with 2D speckle tracking echocardiography (2D-STE). The aim of the present study was to evaluate whether reduced fetal growth is associated with cardiac left-ventricle (LV) dysfunction, using 2D-STE software widely used in postnatal echocardiography. A prospective longitudinal cohort study was performed, and global (GLO) and segmental LV longitudinal strain was measured offline and compared between FGR and appropriate-for-gestational-age (AGA) fetuses throughout gestation. All cases of FGR fetuses were paired 1:2 to AGA fetuses, and linear mixed model analysis was performed to compare behavior differences between groups throughout pregnancy. Our study shows LV fetal longitudinal strain in FGR and AGA fetuses differed upon diagnosis and behaved differently throughout gestation. FGR fetuses had lower LV strain values, both global and segmental, in comparison to AGA, suggesting subclinical cardiac dysfunction. Our study provides more data regarding fetal cardiac function in cases of placental dysfunction, as well as highlights the potential use of 2D-STE in the follow-up of cardiac function in these fetuses

Echocardiography

The book "Echocardiography - New Techniques" brings worldwide contributions from highly acclaimed clinical and imaging science investigators, and representatives from academic medical centers. Each chapter is designed and written to be accessible to those with a basic knowledge of echocardiography. Additionally, the chapters are meant to be stimulating and educational to the experts and investigators in the field of echocardiography. This book is aimed primarily at cardiology fellows on their basic echocardiography rotation, fellows in general internal medicine, radiology and emergency medicine, and experts in the arena of echocardiography. Over the last few decades, the rate of technological advancements has developed dramatically, resulting in new techniques and improved echocardiographic imaging. The authors of this book focused on presenting the most advanced techniques useful in today's research and in daily clinical practice. These advanced techniques are utilized in the detection of different cardiac pathologies in patients, in contributing to their clinical decision, as well as follow-up and outcome predictions. In addition to the advanced techniques covered, this book expounds upon several special pathologies with respect to the functions of echocardiography

Twin-twin transfusion syndrome (TTTS) : outcomes with special reference to cardiovascular function

Background Fetal environment has become a subject for increasing interest when studying health and disease in adults. Monozygous (MZ) twins, especially gestations complicated with twin - twin transfusion syndrome (TTTS), offer a unique opportunity to study adverse developmental programming of the cardiovascular system. TTTS affects about 10% of pregnancies with a common placenta because of unbalanced blood flow across deep arteriovenous connecting vessels . The d ivergent hemodynamic load s of the donor and the recipie nt fetus often result in myocardial hypertrophy of the recipient heart. The aims of this thesis were to evaluate intrauterine environmental contributions to vascular functions in twins with discordant birth weight (Paper I), to study long term effects of TTTS on cardiac structure and function (Paper II and IV) and to determine infant survival and neonatal outcome after fetoscopic laser coagulation therapy of TTTS in Sweden (Paper III). Methods and Results An observational study of 31 twin - pairs, mean age 8 years, with discordant weight at birth, showed that systolic blood pressure (SBP) was higher and endothelial function lower in the at birth smaller twin. In MZ twins with a history of TTTS (n= 9 pairs), there was no significant difference in SBP, but do nor twins had narrower carotid arteries than recipient twins and carotid strain was higher (Paper I). Echocardiography of 11 TTTS twin - pairs, mean age 9.6 years, prenatally treated with amnioreductions, showed no difference in cardiac structure but recip ients had significantly lower diastolic ventricular filling compared with donors (Paper II). When examining a laser treated cohort of 19 TTTS twin - pairs, mean age 4.5 years, and 19 age - matched singleton controls, we found signs of a minor decrease in early diast olic ventricular filling in recipients compared with donors, but no difference s in heart function or structure compared with controls (Paper IV). From a hospital - based register of the first Swedish cohort of laser treated TTTS pregnancies (n = 71), we found that overall survival from treatment to one - year of age was 46%, and that in 61% of gestations, at least one twin survived infancy. Mean gestational age at birth was 30 weeks and mechanical ventilation was needed in 46% of live born twins (Paper III). Conclusions Exposure to fetal growth retardation may contribute to higher blood pressure , arterial narrowing and endothelial dysfunction in childhood (Paper I). Fetal and infant survival after fetoscopic laser coagulation of TTTS is still l imited . I f very preterm delivery is necessary, the neonatal team has to prepare for taking care of two high risk neonates mostly requiring respiratory support (Paper III). Despite different and severe fetal cardiac loading conditions, our long - term follow - up studie s of twins surviving TTTS showed an overall cardiac structure and function within normal range. The signs of reduced diastolic function found in the group treated with amnioreductions (Paper II) were less pronounced in the laser treated cohort (Paper IV). These observations indicate that the cardiac morbidity caused by TTTS resolves in childhood. This has important implications as clinical decision making in TTTS frequently involves choosing between accepting increased fetal cardiac morbidity in the recipi ent twin and delivery of two very preterm babies

Biventricular function on early echocardiograms in neonatal hypoxic–ischaemic encephalopathy

AimTo compare early (<24 hours) echocardiograms (ECHOs) in infants with perinatal hypoxic–ischaemic encephalopathy (HIE) undergoing (i) therapeutic hypothermia (TH), (ii) normothermia and (iii) normal controls.MethodsThis was a single‐centre retrospective review of clinical early ECHOs of term infants with moderate or severe HIE and controls (with a normal ECHO <72 hours of age). Right (RVO) and left ventricular output (LVO), RV and LV myocardial performance index (MPI), systolic to diastolic duration ratio (S/D) and eccentricity indices (EI) in systole and diastole were compared using ANOVA.ResultsAmong infants with HIE (n = 56, 38 in the TH and 18 in normothermia groups), 14 (25%) infants died and 42 survived. Significantly elevated biventricular MPI, lower RVO and LVO and pulmonary hypertension (abnormal EI, higher RV S/D and bidirectional or right‐to‐left ductal shunt) were found in groups with HIE, compared to controls (n = 35). LV MPI was lower in HIE‐TH, compared to the HIE‐normothermia group. Infants with HIE who died (n = 14) had a significantly lower EId [0.77 (0.09) vs. 0.83 (0.08), p = 0.021] compared to survivors (n = 42).ConclusionInfants with perinatal HIE have ventricular dysfunction; those who died had significantly lower EId than survivors; this association needs to be further validated.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137559/1/apa13866_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137559/2/apa13866.pd

Comprehensive Evaluation of Right Heart Performance and Pulmonary Hemodynamics in Neonatal Pulmonary Hypertension: Evaluation of cardiopulmonary performance in neonatal pulmonary hypertension

Purpose of review: Pulmonary hypertension is characterized by an elevation of pulmonary artery pressures and prolonged exposure of the right ventricle to high afterload that collectively contribute to morbidity and mortality in both the term and preterm infants. This review summarizes the pathogenesis, etiologies, and hemodynamic profiles of the conditions that result in pulmonary hypertension in neonates. We explore the application of echocardiographic techniques for the assessment of right ventricular performance and pulmonary hemodynamics that enhance and guide the diagnosis and management strategies in neonates. Recent findings: Clinical assessments based on the determinants of mean pulmonary artery pressures (pulmonary vascular resistance, pulmonary blood flow, and pulmonary capillary wedge pressure) provide a physiologic approach in determining the acute and chronic etiologies of pulmonary hypertension in neonates. In addition, advances in neonatal echocardiography now afford the capability to obtain quantitative information that often precedes the qualitative information acquired by conventional methods and also provide sensitive markers of right ventricle performance for prognostic information based on the determinants of mean pulmonary artery pressures. Summary: Neonatal pulmonary hypertension represents a physiologic spectrum that accounts for the variance in clinical presentation and response to therapies. Physiology-based approaches to etiological identification, coupled with the emerging echocardiographic methods for the assessment of pulmonary hypertension in neonates will likely help to identify cardiovascular compromise earlier, guide therapeutic intervention, monitor therapeutic effectiveness, and improve overall outcome