Prenatally diagnosed pseudoaneurysm of mitral-aortic intervalvular fibrous area.

The mitral-aortic intervalvular fibrosa (MAIVF) is an avascular, fibrous structure that provides continuity between the anterior leaflet of the mitral valve and the aortic valve. Pseudoaneurysm of the MAIVF is rare and has been most commonly described in adults and, more rarely, in children following cardiac surgery or endocarditis. Few reports have been published on cases with congenital pseudoaneurysm of the MAIVF. Here, we describe five cases of congenital pseudoaneurysm of the MAIVF identified prenatally and an additional six cases diagnosed postnatally. This is an unusual finding of varying clinical significance, which can be isolated or associated with complex congenital heart disease but, importantly, can be identified and monitored in the fetus. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Severe left diaphragmatic hernia limits size of fetal left heart more than does right diaphragmatic hernia.

OBJECTIVES: To assess whether severity of congenital diaphragmatic hernia (CDH) correlates with the degree of left heart hypoplasia and left ventricle (LV) output, and to determine if factors leading to abnormal fetal hemodynamics, such as compression and reduced LV preload, contribute to left heart hypoplasia. METHODS: This was a retrospective cross-sectional study of fetuses at 16-37 weeks' gestation that were diagnosed with CDH between 2000 and 2010. Lung-to-head ratio (LHR), liver position and side of the hernia were determined from stored ultrasound images. CDH severity was dichotomized based on LHR and liver position. The dimensions of mitral (MV) and aortic (AV) valves and LV were measured, and right and left ventricular outputs were recorded. RESULTS: In total, 188 fetuses with CDH were included in the study, 171 with left CDH and 17 with right CDH. Fetuses with severe left CDH had a smaller MV (Z = -2.24 ± 1.3 vs -1.33 ± 1.08), AV (Z = -1.39 ± 1.21 vs -0.51 ± 1.05) and LV volume (Z = -4.23 ± -2.71 vs -2.08 ± 3.15) and had lower LV output (26 ± 10% vs 32 ± 10%) than those with mild CDH. MV and AV in fetuses with right CDH (MV, Z = -0.83 ± 1.19 and AV, Z = -0.71 ± 1.07) were larger than those in fetuses with left CDH, but LV outputs were similarly diminished, regardless of hernia side. Severe dextroposition and abnormal liver position were associated independently with smaller left heart, while LHR was not. CONCLUSION: The severity of left heart hypoplasia correlates with the severity of CDH. Altered fetal hemodynamics, leading to decreased LV output, occurs in both right- and left-sided CDH, but the additional compressive effect on the left heart is seen only when the hernia is left-sided. Improved knowledge of the physiology of this disease may lead to advances in therapy and better risk assessment for use in counseling affected families.

Contribution of serum inflammatory markers to changes in bone mineral content and density in postmenopausal women: a 1-year investigation.

Bone formation and resorption are influenced by inflammatory processes. We examined the relationships among inflammatory markers and bone mineral content (BMC) and density (BMD) and determined the contribution of inflammatory markers to 1-yr changes in BMC and BMD in healthy postmenopausal women. This analysis included 242 women at baseline from our parent Soy Isoflavones for Reducing Bone Loss project who were randomly assigned to 1 of 3 treatment groups: placebo, 80 mg/d soy isoflavones, or 120 mg/d soy isoflavones. BMD and BMC from the lumbar spine (LS), total proximal femur (hip), and whole body were measured by dual energy X-ray absorptiometry and the 4% distal tibia by peripheral quantitative computed tomography. Serum inflammatory markers (C-reactive protein, interleukin [IL]-1 beta, IL-6, tumor necrosis factor-alpha [TNF-alpha], and white blood cell count [WBC]) were measured at baseline, 6, and 12 mo. Because of attrition or missing values, data analysis at 12 mo includes only 235 women. Significant associations among IL-6, TNF-alpha, and WBC were observed with percent change in LS, hip, and whole body BMC and BMD. Multiple regression analysis indicated that in combination inflammatory markers accounted for 1.1-6.1% of the variance to the observed 12-mo changes in BMC and BMD. Our results suggest that modifying inflammatory markers, even in healthy postmenopausal women, may possibly reduce bone loss.

NOD1 and NOD2 mediate sensing of periodontal pathogens.

In bacterial infection, Nucleotide-binding Oligomerization Domain (NOD) 1 and NOD2 induce innate immune responses by recognizing fragments of the bacterial component peptidoglycan (PGN). To determine the roles of these receptors in detection of periodontal pathogens, we stimulated human embryonic kidney cells expressing NOD1 or NOD2 with heat-killed Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Fusobacterium nucleatum or their soluble PGNs (sPGNs). All bacteria and their sPGNs could stimulate activation of NF-kappaB. However, there were differences in NOD1- and NOD2-stimulatory activities among the species of bacteria. P. gingivalis showed weaker NOD1- and NOD2-stimulatory activities than did other bacteria. These differences in activities were confirmed by production of interleukin-8 from oral epithelial cells stimulated with sPGNs. These findings indicate that both NOD1 and NOD2 might be involved in the recognition of periodontal pathogens, and that the weak NOD-stimulatory property of P. gingivalis might be helpful for survival in the periodontal pocket.

Specificity and signaling in the Drosophila immune response.

The Drosophila immune response is characterized by the rapid and robust production of a battery of antimicrobial peptides immediately following infection. The genes encoding these antimicrobial peptides are controlled by two NF-κB signaling pathways that respond to microbial infection. The IMD pathway is triggered by DAP-type peptidoglycan, from the cell wall of most Gram-negative and certain Gram-positive bacteria, and activates the NF-κB precursor protein Relish. The Toll pathway, on the other hand, is stimulated by lysine-type peptidoglycan from many Gram-positive bacteria, ß 1,3 glucans from many fungi, as well as by microbial proteases. Toll signaling leads to the activation and nuclear translocation of DIF or Dorsal, two other NF-κB homologs. This review presents our current understanding of the molecular mechanisms involved in microbial recognition and signal transduction in these two innate immune pathways.

Peptidoglycan recognition in Drosophila.

Drosophila rely primarily on innate immune responses to effectively combat a wide array of microbial pathogens. The hallmark of the Drosophila humoral immune response is the rapid production of AMPs (antimicrobial peptides) by the fat body, the insect homologue of the mammalian liver. Production of these AMPs is controlled at the level of transcription by two NF-kappaB (nuclear factor kappaB) signalling pathways. The Toll pathway is activated by fungal and many Gram-positive bacterial microbes, whereas the IMD (immune deficiency) pathway responds to Gram-negative bacteria and certain Gram-positive bacilli. In the present review, we discuss the mechanisms involved in bacterial recognition, in particular the differential recognition of various types of bacterial PGN (peptidoglycan) by different members of the PGRP (PGN recognition protein) family of receptors.

Diagnosis of patent ductus arteriosus by a neonatologist with a compact, portable ultrasound machine.

OBJECTIVES: To conduct a pilot study assessing a neonatologist's accuracy in diagnosing patent ductus arteriosus (PDA) using compact, portable ultrasound after limited training. STUDY DESIGN: Prospective study of premature infants scheduled for echocardiography for suspected PDA. A neonatologist with limited training performed study exams before scheduled exams. Sensitivity and specificity were calculated, compared to the scheduled echocardiogram interpreted by a cardiologist. RESULTS: There were 24 exams. Compared to the scheduled exam, the neonatologist's exam had sensitivity 69% (95% confidence interval (CI), 41 to 89%) and specificity 88% (95% CI, 47 to 99%). When a cardiologist interpreted the study exams, the sensitivity was 87% (95% CI, 60 to 98%) and specificity 71% (95% CI, 29 to 96%). CONCLUSION: A neonatologist with limited training was able to detect PDA with moderate success. A more rigorous training process or real-time transmission with cardiologist interpretation may substantially improve accuracy. Institutions with experienced technicians and on-site pediatric cardiologists may not gain from intensive training of neonatologists, but hospitals where diagnosis and treatment of PDA would be delayed may benefit from such processes.

Successful use of oral ganciclovir for the treatment of intrauterine cytomegalovirus infection in a renal allograft recipient.

Congenital cytomegalovirus (CMV) infection occurs in approximately 1% of newborns and is the leading infectious cause of congenital birth defects. Female renal allograft recipients who develop CMV infection during pregnancy are at risk for both graft dysfunction and fetal morbidity. DNA-based analysis of amniotic fluid (AF) from at-risk pregnancies has been suggested as an adjunct/substitute for traditional culture. We have shown that CMV-polymerase chain reaction of AF is a useful diagnostic test for congenital CMV infection. Using this test we diagnosed CMV infection in the fetus of a 30-year-old renal transplant recipient. As termination was not an option for the family, the patient was extensively counseled and treated with oral ganciclovir. This resulted in clearance of the virus from the AF and the delivery of a healthy newborn girl, free of CMV disease. This is the first reported case to our knowledge of successful use of maternal ganciclovir to treat intrauterine CMV infection in a pregnant renal transplant recipient.

The impact of fetal echocardiography.

Fetal echocardiography has impacted the fetus with congenital heart disease in many important ways. Advances in fetal echocardiography have allowed for more accurate and earlier detection of cardiac abnormalities. In turn, the prenatal diagnosis of cardiac abnormalities has improved the care and outcome of selected fetuses with severe cardiac malformations or arrhythmias. Fetal echocardiography has improved the understanding of the development and evolution of congenital heart disease in utero, and it may serve a role in identifying candidates for prenatal intervention. The prenatal diagnosis of congenital heart disease has allowed for better counseling and preparation of families regarding the anticipated prenatal development of the fetus as well as the expected postnatal management plans and prognosis. This article reviews the impact of fetal echocardiography in these and other areas.

Congenital absence of aortic valvar leaflets: a rare variant of the hypoplastic left heart syndrome.

Congenital absence of aortic valvar leaflets is a rare and fatal variant of the hypoplastic left heart syndrome. We describe a recent patient seen at our institution with this lesion, illustrating a combined echocardiographic and angiographic approach that delineates both anatomy and physiology. The early mortality experienced in previous reports, as well as unsuccessful surgical palliation in our case, should promote further discussion regarding the optimal treatment.

Neonatal repair of truncus arteriosus: continuing improvement in outcomes.

BACKGROUND: Repair of truncus arteriosus in the neonatal and early infant periods has become standard practice at many centers. We reviewed our recent experience with repair of truncus arteriosus in neonates, with a focus on early and intermediate outcomes. METHODS: From July 1992 to December 1999, 65 patients 1 month of age or less underwent primary complete repair of truncus arteriosus. Median age was 10 days, and median weight was 3.2 kg. Major associated anomalies included moderate or severe truncal valve regurgitation in 15 patients (23%), interrupted aortic arch in 8 (12%), coronary artery abnormalities in 12 (18%), and nonconfluence of the pulmonary arteries in 3 (5%). Median durations of cardiopulmonary bypass and cardioplegic arrest were 172 minutes and 90 minutes, respectively. Circulatory arrest was employed only in 7 patients undergoing concomitant repair of interrupted arch. Reconstruction of the right ventricular outflow tract was achieved with an aortic (n = 39) or pulmonary (n = 26) allograft valved conduit (median diameter, 12 mm). Replacement (n = 6) or repair (n = 5) of a regurgitant truncal valve was performed in 11 patients, and interrupted arch was repaired in 8. RESULTS: There were three early deaths (5%). Early reoperations included reexploration for bleeding in 3 patients, emergent replacement of a pulmonary outflow conduit that failed acutely in 1 patient, and placement of a permanent pacemaker in 1. Mechanical circulatory support was required in 1 patient. During the median follow-up of 32 months, there were two deaths. The Kaplan-Meier estimate of survival was 92% at 1 year and beyond. The only demographic, diagnostic, or operative factors significantly associated with poorer survival over time were operative weight of 2.5 kg or less (p = 0.01) and truncal valve replacement (p = 0.009). Actuarial freedom from conduit replacement among early survivors was 57% at 3 years. CONCLUSIONS: Repair of truncus arteriosus in the neonatal period can be performed routinely with excellent survival, even in patients with major associated abnormalities.

Unrecognized esophageal perforation in a neonate during transesophageal echocardiography.

Esophageal perforation caused by transesophageal echocardiography in an infant is believed to be extremely rare. If unrecognized, serious morbidity can result. We report a case of pharyngeal perforation in a neonate undergoing an interrupted aortic arch repair.

Systemic venous abnormalities: embryologic and echocardiographic considerations.

The echocardiographic diagnosis of systemic venous anomalies often is rendered difficult by the variety of lesions that exist. An understanding of the embryologic processes that result in these lesions is essential for accurate identification, since these lesions often are not obvious on routine echocardiographic examination. Standard echocardiographic views may demonstrate some lesions, whereas many require modified views to outline the abnormal systemic venous anatomy. This paper reviews the basic embryologic processes of the development of the normal and abnormal systemic venous system, as well as the echocardiographic identification of these major systemic venous malformations.

Testing the taxonomic integrity of Paranthropus boisei sensu stricto.

The craniodental hypodigm of Paranthropus boisei sensu stricto is morphologically distinctive, but it has been suggested that the substantial variation in mandibular and dental size in that hypodigm may exceed that which is reasonable to subsume within a single hominin species. In this study, Fligner and Killeen, coefficient of variation (CV)-based and average taxonomic distance (ATD)-based bootstrap tests, were used to compare variation in size and shape of the mandibular corpus remains attributed to P. boisei s.s. with the variation observed in samples of great apes and modern humans. The degree of size variation in the P. boisei s.s. mandibular hypodigm is never observed in human and chimpanzee samples, is rare in gorillas, but is not uncommon in orangutans. However, the shape variation in the fossil group is comparable to the variation in the extant reference groups. Although the size variation in P. boisei s.s. is substantial, it is exaggerated by the effects of taphonomy. The small mandibles are more often abraded, whereas the large mandibles are more likely to have been infiltrated with matrix. On the basis of the results of this investigation of the mandibular corpus, there are no grounds for rejecting the "single-species" hypothesis for P. boisei s.s. When Sokal and Braumann's adjusted CV values were used to predict the index of sexual dimorphism (ISD) for the P. boisei s.s., despite the substantial geological time embraced by the mandibular corpus hypodigm, the predicted value of lnISD, when corrected for taphonomic factors, is comparable to the sexual dimorphism observed within Gorilla.

A blood pressure sensor for long-term implantation.

An implantable flow-through blood pressure sensor prototype has been developed for use with an implantable left ventricular assist device (LVAD). This sensor incorporates a flat pressure-sensing diaphragm that is designed to be integral with the wall of a titanium tube that may be placed in the inlet or the outlet flow path of any LVAD. The interior tube flow geometry is transitioned from a round to a D-shape such that flow separation is eliminated. Bench testing of 3 sensors was performed to characterize the sensor. The worst-case results showed a maximum nonlinearity of 0.64 mm Hg, a maximum hysteresis of 0.87 mm Hg, and a maximum nonrepeatability of 0.87 mm Hg. Long-term drift studies of 2 sensors at 193 days and 112 days resulted in a projected annual drift rate of 1.4 and 2.0 mm Hg, respectively. The APEX pressure sensors were evaluated in 5 ventricular assist acute calf experiments in which the sensor outputs were compared with Millar pressure catheter sensors. Pressure output comparisons showed similar pressure tracings. No visible evidence of thrombus formation was found on the APEX sensor compared with thrombus formation found on the Millar catheter at the entrance to the flow path. Tests demonstrated that the blood pressure sensor can accurately measure blood pressure and indicate that it has long-term stability.

Prenatal diagnosis of congenital nephrosis by in utero kidney biopsy.

The diagnosis of congenital nephrosis is difficult during the antepartum period. The combination of an elevated amniotic fluid alpha-fetoprotein, a negative acetylcholinesterase, and a negative ultrasound examination is highly indicative of congenital nephrosis; however, these findings can also be associated with a normal gestation. This is the first report of pathologic confirmation of congenital nephrosis from an in utero fetal kidney biopsy.

Evaluation of fetal heart dimensions from 12 weeks to term.

To evaluate whether fetal cardiac measurements can be made in the second trimester, we examined a cohort of normal pregnancies between 12 and 18 weeks' gestation using state-of-the-art ultrasound equipment. We examined this population longitudinally at intervals of 2 weeks, as well as at 32 weeks' gestation. From the 4-chamber view we measured the ventricular and atrial cavity dimensions, the thickness of the ventricular walls and septum at end-diastole, and the annulus dimensions of the mitral and tricuspid valves. Using a variety of views we also measured the long and cross-sectional diameters of the atria, the aorta, the pulmonary artery and its main left and right branches, the ductus arteriosus, and the superior and inferior vena cavae. To test the frequency with which measurements could be made, we divided them into measurements that were clear and easy to define (statistically good), to those that were unclear (statistically bad), or those that were not measured at all (none). Data were then analyzed by regression analysis, analysis of variance, and covariance. The frequency of reliable measurements varied inversely with gestational age. The inflection point for measurements was approximately at 16 weeks. Data from this longitudinal study were evaluated against those obtained from our previous study. Because no statistical differences were found in measurements between these studies where they overlapped, the data were pooled into 1 large group and the mean and SEEs calculated for all variables. Our study demonstrates that with current transabdominal imaging, fetal cardiac measurements can be made reliably in normal fetuses from 16 weeks' gestation onward. The frequency of obtaining data in younger normal fetuses suggests it is unlikely that reliable observations can be made routinely in abnormal fetuses < 16 weeks old, although this might be possible in individual fetuses.