Fetal 24-Segment Sphericity Index and Ventricular Fractional Shortening Between 12 and 20 Weeks of Gestation.

BACKGROUND: Although the fetal sphericity index (SI) and fractional shortening (FS) of 24 transverse segments have been previously reported after the 20th gestational week, there have been no reports during the first and early second trimester. OBJECTIVE: This study aimed to clarify the SI and FS of 24 transverse segments in normal fetuses before the 20th gestational week. METHODS: A total of 101 normal fetuses aged between 12 and 20 gestational weeks were examined. The displacement of the ventricular endocardium during the cardiac cycle was computed using speckle-tracking software (GE Healthcare, Milwaukee, WI). We analyzed the length of 24 end-diastolic lateral segments and the end-diastolic basal (seg1-6)- middle (Seg7-15)-apical (Seg16-24) distribution from the base to the apex of each ventricle, according to the method described by DeVore et al. The SI and FS were computed for each of the 24 segments by dividing the mid-basal-apical length by the transverse size. RESULTS: The SI for each segment was independent of the gestational age. The SI of the right ventricle was significantly lower than that of the left ventricle for segments 1-14, suggesting that the right ventricle was more spherical than the left ventricle in the basal segment only. The FS of the right ventricle was significantly lower than that of the left ventricle in segments 1 to 2 and 13 to 24. CONCLUSION: The morphology of the ventricles before 20 weeks of gestation differs from that between 20 and 40 weeks of gestation. This difference may be related to myocardial densification or performance.

Quantitative Analysis of Morphology and Function in the Fetal Heart with Severe Tricuspid Regurgitation by Speckle Tracking Imaging.

Morphology and function in a fetal heart with severe tricuspid regurgitation remains challenging. The aim of this study was to assess cardiac morphology and function in fetuses with severe tricuspid regurgitation by fetal heart quantification (HQ) and to assess the practical value of fetal HQ. Clinical information was analyzed for 63 pregnant women who underwent fetal cardiac ultrasonography. The women were divided into those who had a fetus with severe tricuspid regurgitation (n = 20) and those with a normal fetus (n = 40). The global sphericity index (GSI), fractional area change (FAC), and global longitudinal strain (GLS) of both ventricles and the sphericity index (SI) and fractional shortening (FS) of 24 segments were quantified by fetal HQ using speckle tracking imaging. Fetuses with severe tricuspid regurgitation had a significantly lower GSI (1.14 ± 0.10 vs. 1.26 ± 0.08, p < 0.001) and a higher GSI Z-score (-0.98 ± 1.01 vs. 0.25 ± 0.87, p < 0.001) as well as a significantly lower right ventricular FAC (36.50 ± 7.34% vs. 45.19 ± 3.39%, p < 0.001), FAC Z-score (-1.02 ± 1.41 vs. 0.49 ± 0.74, p < 0.001), and GLS (-21.01 ± 5.66% vs. 45.19 ± 3.49%, p < 0.001). The SI and SI Z-score were significantly lower in segments 1-18 of the right ventricle in fetuses with severe tricuspid regurgitation (p < 0.05); furthermore, FS of segments 1-12 and 19-24 and the FS Z-score of segments 18-24 were significantly lower in fetuses with severe tricuspid regurgitation (p < 0.05). Fetal HQ is useful for evaluation of cardiac morphology and function in fetuses with severe tricuspid regurgitation and can provide important reference information for both clinical diagnosis and treatment.

Fetal cardiac function at midgestation and conception by in-vitro fertilization.

OBJECTIVE: To assess differences in cardiac morphology and function at midgestation in fetuses conceived by in-vitro fertilization (IVF), using fresh or frozen embryo transfer, compared with those conceived naturally. METHODS: This was a prospective study of 5801 women with a singleton pregnancy attending for a routine ultrasound examination at 19 + 0 to 23 + 6 weeks' gestation, including 343 that conceived by IVF. Conventional and more advanced echocardiographic modalities, including speckle-tracking analysis, were used to assess fetal cardiac function in the right and left ventricles. The morphology of the fetal heart was assessed by calculating the right and left sphericity index. Placental perfusion and function were assessed by measurement of uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF), respectively. RESULTS: Fetuses that were conceived by IVF, compared with those conceived spontaneously, had significantly lower right and left ventricular sphericity index, higher left ventricular global longitudinal strain and lower left ventricular ejection fraction. There were no significant differences in any of the cardiac indices within the IVF group between the fresh and frozen embryo transfers. In the IVF group, compared with spontaneously conceived pregnancies, UtA-PI was lower and PlGF was higher, suggesting better placental perfusion and function. CONCLUSIONS: Our study demonstrates that, in IVF pregnancies, compared with those conceived spontaneously, there is evidence of fetal cardiac remodeling at midgestation, which is not related to the use of fresh or frozen embryo transfer. In the IVF group, compared with naturally conceived pregnancies, fetal heart was globular and left ventricular systolic function was mildly reduced. Whether these cardiac changes are accentuated later in pregnancy and remain in the postnatal period remains to be established. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal cardiac function evaluation: A review.

The aim of this review is to provide an up to date on the current use of fetal echocardiography in assessing the fetal cardiac function and its potential research and clinical applications. Despite classically is been used for prenatal diagnosis of fetal heart defects, assessment of fetal cardiac function has been recently proposed as a fundamental tool to assess pregnancies complicated by several disorders with long-term impact on post-natal cardiovascular health, such as placental insufficiency and fetal growth restriction. In this review we present anatomical and functional fetal cardiac development mechanisms and an overview of the currently available techniques for evaluating fetal heart function.

Role of global sphericity index in evaluation of fetal cardiac remodeling in late onset fetal growth restriction and small for gestational age fetuses.

INTRODUCTION: Fetal growth restriction (FGR) fetuses develop cardiovascular remodeling and dysfunction and, in this process, heart first compensates by changing its shape from ellipsoid to spherical and then cardiac dysfunction follows. Our aim was to evaluate global sphericity index (GSI) after 32 weeks of gestation to evaluate this change in cardiac shape and correlate GSI changes associated with fetal growth abnormalities. MATERIALS AND METHODS: This was a prospective study conducted at 32-38 weeks of gestation. Women were classified into three groups-Appropriate for gestational age (AGA), small for gestational age (SGA), late onset FGR (LO FGR) and GSI was measured and perinatal outcome studied. RESULTS: Out of 217 women, 131 were of AGA, 31 were SGA, 55 were of late onset FGR. SGA and late onset FGR groups had low GSI compared to AGA group. There was no significant difference in mean GSI between late onset FGR and SGA groups. Neonatal morbidity, adverse perinatal outcomes did not significantly differ with GSI in SGA and late onset FGR groups. CONCLUSION: This study showed that late gestation small fetuses develop early stages of cardiovascular remodeling as shown by GSI changes. These changes were independent of Doppler changes. This supports the concept that atleast a proportion of them are not constitutionally small but are true forms of FGR.

Assessing Non-invasive Studies to Evaluate Resynchronization Pacing Effectiveness in the Young.

Appropriate non-invasive assessments (ECHO/ECG) of cardiac resynchronization pacing therapy (CRT) among younger patients (pts) with/without (w/wo) congenital heart disease (CHD) are not established. Ejection fraction (EF) and QRS can be unreliable due to anatomy, surgical repairs, and pre-existing pacemakers (PM). This study correlates updated non-invasive studies, including newer strain values, with clinical and invasive hemodynamic assessments of CRT response in the young. Sixteen pts (mean age 18.5 ± 6 years, 10/16 with pre-existing pacemakers) underwent CRT for heart failure (NYHA II-III). CHD included septal defects and Tetralogy of Fallot. Assessment of CRT efficacy was based on clinical findings, direct catheterization studies [pressures, contractility indices (dP/dt-max)], ECG changes, and ECHO studies [including updated global (GLS), left atrial strain (LAS), and sphericity indices] pre- and at 1-month and 1-year post-CRT. After 1 year following CRT, all pts improved (II-III to I-II) in clinical NYHA status. Contractility (dP/dt) increased (932 ± 351 vs 561 ± 178.7 mmHg-sec [p = 0.001]). QRS duration shortened only among pts with pre-existing PM (160 ± 25 vs 134 ± 25 ms [p = 0.02]). Standard ECHO parameters, including chamber dimensions and EF, showed no appreciable changes from pre-CRT values. However, endocardial GLS [(- 6.4 vs. - 9.6%) p = 0.0003] and LAS [(- 5.8 vs - 9.3%) p = 0.02] values significantly improved. Although CRT is applicable to younger pts, accurate non-invasive evaluations of response are lacking. This study establishes that newer strain values better correlate with clinical and hemodynamic changes over other parameters and offer more appropriate assessments of CRT response.

The Role of Extracellular Matrix in the Experimental Acute Aortic Regurgitation Model in Rats.

BACKGROUND: Mechanisms involved in cardiac remodelling by aortic regurgitation (AR) and the moment when cardiac dysfunction begins are largely unknown. This study aimed to investigate cardiac morphology and function after 1, 4, 8, and 12 weeks of experimental AR in Wistar rats. Extracellular matrix was also investigated as the potential mechanism that underlies the AR remodelling process. METHODS: Male Wistar rats underwent surgical acute AR (AR group, n=51) or a sham surgery (sham group, n=32). After the procedure, serial transthoracic echocardiograms were performed at 1, 4, 8, and 12 weeks. Morphometry of cardiac tissue and the activities of metalloproteinase 2 (MMP-2) and tissue metalloproteinase inhibitor-1 (TIMP-1) were analysed. Statistical analysis was performed by two-way ANOVA. Significance level was 5%. RESULTS: The AR group presented an increase in the sphericity index (week 1); an increase in the left atrium, left ventricular mass index, TIMP-1 and MMP-2 activities, and collagen fraction (week 4); an increase in myocyte area (week 8); and a reduction in fraction shortening (week 12). First, the chamber became more spherical; second, MMP-2 and TIMP-1 were activated and this may have contributed to hypertrophy and atrial enlargement, until systolic dysfunction occurred. CONCLUSIONS: This study showed a sequence of abnormalities that preceded myocardial dysfunction in an experimental model of AR. First, haemodynamic volume overload led to a more spherical left ventricle chamber. Second, MMP-2 and TIMP-1 transitorily increased and may have contributed to atrial enlargement, eccentric hypertrophy, and systolic dysfunction.

Impact of gestational diabetes mellitus on fetal cardiac morphology and function: cohort comparison of second- and third-trimester fetuses.

OBJECTIVES: To assess differences in cardiac morphology and function in fetuses of mothers with gestational diabetes mellitus (GDM) compared to controls, and to assess whether, in women with GDM, fetal cardiac changes are accentuated with advancing gestational age. METHODS: We studied 112 women with GDM and 224 women with uncomplicated pregnancy at 24-40 weeks' gestation. In all fetuses, a standard four-chamber oblique view was obtained and offline speckle-tracking analysis was performed to measure right and left endocardial global longitudinal strain (GLS) and tricuspid and mitral annular plane systolic excursion. Global sphericity index was also calculated. Echocardiographic parameters were compared between GDM fetuses and controls at two gestational time periods of 24 + 0 to 32 + 0 weeks and 32 + 1 to 40 + 1 weeks. RESULTS: At 24 + 0 to 32 + 0 weeks, we phenotyped 43 fetuses from mothers with GDM and 71 from uncomplicated pregnancies, and, at 32 + 1 to 40 + 1 weeks, we phenotyped 69 fetuses from mothers with GDM and 153 from women with uncomplicated pregnancy. In fetuses of mothers with GDM, compared to controls, right ventricular functional indices were consistently lower both at 24 + 0 to 32 + 0 weeks and at 32 + 1 to 40 + 1 weeks. Right ventricular GLS was reduced in the GDM group at 24 + 0 to 32 + 0 weeks (adjusted mean difference, 0.7%; 95% CI, 0.3-1.1%) and at 32 + 1 to 40 + 1 weeks (adjusted mean difference, 0.9%; 95% CI, 0.6-1.1%). Fetal left ventricular global longitudinal function was similar in GDM pregnancies compared with controls, with the exception of the contractility of the left ventricular basal segment, which was reduced. Global sphericity index was reduced in GDM pregnancies only at 32 + 1 to 40 + 1 weeks (adjusted mean difference, -0.4; 95% CI, -0.7 to 0.1). CONCLUSIONS: The offspring of women with GDM are at high risk for development of cardiovascular disease in childhood and early adulthood. Our study demonstrates that GDM is associated with a reduction mainly in fetal right ventricular function, compared to controls, and this response is not exaggerated with increasing gestational age. Further studies are needed to determine whether fetuses with the observed alterations in cardiac function are those at highest risk for subsequent development of cardiovascular disease. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Predictors of functional mitral regurgitation recurrence after percutaneous mitral valve repair.

We aimed to identify predictors of mitral regurgitation recurrence (MR) after percutaneous mitral valve repair (PMVR) in patients with functional mitral regurgitation (FMR). Patients with FMR were enrolled who underwent PMVR using the MitraClip® device. Procedural success was defined as reduction of MR of at least one grade to MR grade ≤ 2 + assessed at discharge. Recurrence of MR was defined as MR grade 3 + or worse at one year after initially successful PMVR. A total of 306 patients with FMR underwent PMVR procedure. In 279 out of 306 patients (91.2%), PMVR was successfully performed with MR grade ≤ 2 + at discharge. In 11.4% of these patients, MR recurrence of initial successful PMVR after 1 year was observed. Recurrence of MR was associated with a higher rate of heart failure rehospitalization during the 12 months follow-up (52.0% vs. 30.3%; p = 0.029), and less improvement in New York Heart Association (NYHA) functional class [68% vs. 19% of the patients presenting with NYHA functional class III or IV one year after PMVR when compared to patients without recurrence (p = 0.001)]. Patients with MR recurrence were characterized by a higher left ventricular sphericity index {0.69 [Interquartile range (IQR) 0.64, 0.74] vs. 0.65 (IQR 0.58, 0.70), p = 0.003}, a larger left atrium volume [118 (IQR 96, 143) ml vs. 102 (IQR 84, 123) ml, p = 0.019], a larger tenting height 10 (IQR 9, 13) mm vs. 8 (IQR 7, 11) mm (p = 0.047), and a larger mitral valve annulus [41 (IQR 38, 43) mm vs. 39 (IQR 36, 40) mm, p = 0.015] when compared to patients with durable optimal long-term results. In a multivariate regression model, the left ventricular sphericity index [Odds Ratio (OR) 1.120, 95% Confidence Interval (CI) 1.039-1.413, p = 0.003)], tenting height (OR 1.207, 95% CI 1.031-1.413, p = 0.019), and left atrium enlargement (OR 1.018, 95% CI 1.000-1.038, p = 0.047) were predictors for MR recurrence after 1 year. In patients with FMR, baseline parameters of advanced heart failure such as spherical ventricle, tenting height and a large left atrium might indicate risk of recurrent MR one year after PMVR.

Cardiac Measurements of Size and Shape in Fetuses With Absent or Reversed End-Diastolic Velocity of the Umbilical Artery and Perinatal Survival and Severe Growth Restriction Before 34 Weeks' Gestation.

OBJECTIVES: The purpose of this study was to evaluate the end-diastolic size and shape of the 4-chamber view as well as the right ventricle (RV) and left ventricle (LV) in growth-restricted fetuses before 34 weeks' gestation with absent or reversed end-diastolic velocity of the umbilical artery and compare the results between those with perinatal deaths and those who survived the neonatal period. METHODS: Forty-nine fetuses with growth restriction and absent or reversed end-diastolic velocity of the umbilical artery were studied. The size, shape, and sphericity index of the 4-chamber view, RV, and LV were assessed. The number and percentage of fetuses with z score values of less than -1.65 and greater than 1.65 were computed. RESULTS: Of the 49 fetuses, there were 13 perinatal deaths (27%) and 36 (63%) neonatal survivors. Measurements that were unique for neonatal survivors were an increased RV apical transverse width and decreased measurements of the following: LV and RV widths, LV and RV areas, as well as RV sphericity indices. CONCLUSIONS: Fetuses with a smaller RV and LV size and area and those with a globular-shaped RV were at significantly lower risk for perinatal death.