1
|
van Amerom JFP, Goolaub DS, Schrauben EM, Sun L, Macgowan CK, Seed M. Fetal cardiovascular blood flow MRI: techniques and applications. Br J Radiol 2023; 96:20211096. [PMID: 35687661 PMCID: PMC10321246 DOI: 10.1259/bjr.20211096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 05/11/2022] [Accepted: 05/24/2022] [Indexed: 11/05/2022] Open
Abstract
Fetal cardiac MRI is challenging due to fetal and maternal movements as well as the need for a reliable cardiac gating signal and high spatiotemporal resolution. Ongoing research and recent technical developments to address these challenges show the potential of MRI as an adjunct to ultrasound for the assessment of the fetal heart and great vessels. MRI measurements of blood flow have enabled the assessment of normal fetal circulation as well as conditions with disrupted circulations, such as congenital heart disease, along with associated organ underdevelopment and hemodynamic instability. This review provides details of the techniques used in fetal cardiovascular blood flow MRI, including single slice and volumetric imaging sequences, post-processing and analysis, along with a summary of applications in human studies and animal models.
Collapse
Affiliation(s)
- Joshua FP van Amerom
- Division of Translational Medicine, SickKids Research Institute, Toronto, Canada
| | | | - Eric M Schrauben
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | | | | | | |
Collapse
|
2
|
Kühle H, Cho SKS, Barber N, Goolaub DS, Darby JRT, Morrison JL, Haller C, Sun L, Seed M. Advanced imaging of fetal cardiac function. Front Cardiovasc Med 2023; 10:1206138. [PMID: 37288263 PMCID: PMC10242056 DOI: 10.3389/fcvm.2023.1206138] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/09/2023] [Indexed: 06/09/2023] Open
Abstract
Over recent decades, a variety of advanced imaging techniques for assessing cardiovascular physiology and cardiac function in adults and children have been applied in the fetus. In many cases, technical development has been required to allow feasibility in the fetus, while an appreciation of the unique physiology of the fetal circulation is required for proper interpretation of the findings. This review will focus on recent advances in fetal echocardiography and cardiovascular magnetic resonance (CMR), providing examples of their application in research and clinical settings. We will also consider future directions for these technologies, including their ongoing technical development and potential clinical value.
Collapse
Affiliation(s)
- Henriette Kühle
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Cardiac and Thoracic Surgery, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany
- Division of Cardiac Surgery, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Steven K. S. Cho
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Nathaniel Barber
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Datta Singh Goolaub
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Jack R. T. Darby
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
| | - Janna L. Morrison
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Early Origins of Adult Health Research Group, University of South Australia, Adelaide, SA, Australia
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Christoph Haller
- Division of Cardiac Surgery, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
3
|
Haxel CS, Johnson JN, Hintz S, Renno MS, Ruano R, Zyblewski SC, Glickstein J, Donofrio MT. Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery. Pediatrics 2022; 150:189887. [PMID: 36317976 DOI: 10.1542/peds.2022-056415c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated. METHODS Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management. RESULTS Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization. CONCLUSIONS Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.
Collapse
Affiliation(s)
- Caitlin S Haxel
- The University of Vermont Children's Hospital, Burlington, Vermont
| | | | - Susan Hintz
- Stanford University, Lucille Salter Packard Children's Hospital, Palo Alto, California
| | - Markus S Renno
- University Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Julie Glickstein
- Columbia University Vagelos School of Medicine, Morgan Stanley Children's Hospital, New York, New York
| | | |
Collapse
|
4
|
Morrison JL, Ayonrinde OT, Care AS, Clarke GD, Darby JRT, David AL, Dean JM, Hooper SB, Kitchen MJ, Macgowan CK, Melbourne A, McGillick EV, McKenzie CA, Michael N, Mohammed N, Sadananthan SA, Schrauben E, Regnault TRH, Velan SS. Seeing the fetus from a DOHaD perspective: discussion paper from the advanced imaging techniques of DOHaD applications workshop held at the 2019 DOHaD World Congress. J Dev Orig Health Dis 2021; 12:153-167. [PMID: 32955011 DOI: 10.1017/s2040174420000884] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Advanced imaging techniques are enhancing research capacity focussed on the developmental origins of adult health and disease (DOHaD) hypothesis, and consequently increasing awareness of future health risks across various subareas of DOHaD research themes. Understanding how these advanced imaging techniques in animal models and human population studies can be both additively and synergistically used alongside traditional techniques in DOHaD-focussed laboratories is therefore of great interest. Global experts in advanced imaging techniques congregated at the advanced imaging workshop at the 2019 DOHaD World Congress in Melbourne, Australia. This review summarizes the presentations of new imaging modalities and novel applications to DOHaD research and discussions had by DOHaD researchers that are currently utilizing advanced imaging techniques including MRI, hyperpolarized MRI, ultrasound, and synchrotron-based techniques to aid their DOHaD research focus.
Collapse
Affiliation(s)
- Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Oyekoya T Ayonrinde
- Fiona Stanley Hospital, Murdoch, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
| | - Alison S Care
- The Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Geoffrey D Clarke
- Department of Radiology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - Justin M Dean
- Department of Physiology, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- The Department of Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, Victoria, Australia
| | | | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences, Kings College London, London, UK
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, Victoria, Australia
- The Department of Obstetrics and Gynecology, Monash University, Melbourne, Victoria, Australia
| | - Charles A McKenzie
- Department of Medical Biophysics, Western University, London, ON, Canada
- Lawson Health Research Institute and Children's Health Research Institute, London, ON, Canada
| | - Navin Michael
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
| | - Nuruddin Mohammed
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, Aga Khan University Hospital, Karachi, Pakistan
| | - Suresh Anand Sadananthan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
| | - Eric Schrauben
- Translational Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Timothy R H Regnault
- Lawson Health Research Institute and Children's Health Research Institute, London, ON, Canada
- Department of Obstetrics and Gynecology, Western University, London, ON, Canada
- Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - S Sendhil Velan
- Singapore Bioimaging Consortium, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
- Singapore Institute for Clinical Sciences, Agency for Science, Technology, and Research (A*STAR), Singapore, Singapore
| |
Collapse
|
5
|
Saini BS, Darby JRT, Marini D, Portnoy S, Lock MC, Yin Soo J, Holman SL, Perumal SR, Wald RM, Windrim R, Macgowan CK, Kingdom JC, Morrison JL, Seed M. An MRI approach to assess placental function in healthy humans and sheep. J Physiol 2021; 599:2573-2602. [PMID: 33675040 DOI: 10.1113/jp281002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 02/15/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Human placental function is evaluated using non-invasive Doppler ultrasound of umbilical and uterine artery pulsatility indices as measures of resistance in placental vascular beds, while measurement of placental oxygen consumption ( V O 2 ) is only possible during Caesarean delivery. This study shows the feasibility of using magnetic resonance imaging (MRI) in utero to measure blood flow and oxygen content in uterine and umbilical vessels to calculate oxygen delivery to and V O 2 by the gravid uterus, uteroplacenta and fetus. Normal late gestational human uteroplacental V O 2 by MRI was ∼4 ml min-1 kg-1 fetal weight, which was similar to our MRI measurements in sheep and to those previously measured using invasive techniques. Our MRI approach can quantify uteroplacental V O 2 , which involves the quantification of maternal- and fetal-placental blood flows, fetal oxygen delivery and V O 2 , and the oxygen gradient between uterine- and umbilical-venous blood, providing a comprehensive assessment of placental function with clinical potential. ABSTRACT It has not been feasible to perform routine clinical measurement of human placental oxygen consumption ( V O 2 ) and in vitro studies do not reflect true metabolism in utero. Here we propose an MRI method to non-invasively quantify in utero placental and fetal oxygen delivery ( D O 2 ) and V O 2 in healthy humans and sheep. Women (n = 20) and Merino sheep (n = 10; 23 sets of measurements) with singleton pregnancies underwent an MRI in late gestation (36 ± 2 weeks and 128 ± 9 days, respectively; mean ± SD). Blood flow (phase-contrast) and oxygen content (T1 and T2 relaxometry) were measured in the major uterine- and umbilical-placental vessels, allowing calculation of uteroplacental and fetal D O 2 and V O 2 . Maternal D O 2 (ml min-1 kg-1 fetus) to the gravid uterus was similar in humans and sheep (human = 54 ± 15, sheep = 53 ± 21, P = 0.854), while fetal D O 2 (human = 25 ± 4, sheep = 22 ± 5, P = 0.049) was slightly lower in sheep. Uteroplacental and fetal V O 2 (ml min-1 kg-1 fetus; uteroplacental: human = 4.1 ± 1.5, sheep = 3.5 ± 1.9, P = 0.281; fetus: human = 6.8 ± 1.3, sheep = 7.2 ± 1.7, P = 0.426) were similar between species. Late gestational uteroplacental:fetal V O 2 ratio did not change with age (human, P = 0.256; sheep, P = 0.121). Human umbilical blood flow (ml min-1 kg-1 fetus) decreased with advancing age (P = 0.008), while fetal V O 2 was preserved through an increase in oxygen extraction (P = 0.046). By contrast, sheep fetal V O 2 was preserved through stable umbilical flow (ml min-1 kg-1 ; P = 0.443) and oxygen extraction (P = 0.582). MRI derived measurements of uteroplacental and fetal V O 2 between humans and sheep were similar and in keeping with prior data obtained using invasive techniques. Taken together, these data confirm the reliability of our approach, which offers a novel clinical 'placental function test'.
Collapse
Affiliation(s)
- Brahmdeep S Saini
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada.,Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Davide Marini
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Sharon Portnoy
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, M5G 0A4, Canada
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Sunthara R Perumal
- Preclinical, Imaging and Research Laboratories, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5086, Australia
| | - Rachel M Wald
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada.,Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, ON, M5G 2N2, Canada
| | - Rory Windrim
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada.,Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1E2, Canada
| | - Christopher K Macgowan
- Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, M5G 0A4, Canada.,Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1L7, Canada
| | - John C Kingdom
- Maternal-Fetal Medicine Division, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada.,Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1E2, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Mike Seed
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5S 1A8, Canada.,Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada.,Translational Medicine, Research Institute, The Hospital for Sick Children, Toronto, ON, M5G 0A4, Canada.,Department of Obstetrics and Gynaecology, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, M5G 1E2, Canada
| |
Collapse
|
6
|
Schrauben EM, Darby JRT, Saini BS, Holman SL, Lock MC, Perumal SR, Seed M, Morrison JL, Macgowan CK. Technique for comprehensive fetal hepatic blood flow assessment in sheep using 4D flow MRI. J Physiol 2020; 598:3555-3567. [PMID: 32533704 DOI: 10.1113/jp279631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/04/2020] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS The comprehensive visualization and quantification of in vivo fetal hepatic haemodynamics, particularly the shunting of ductus venosus blood, has been elusive and is not yet fully understood. We introduce the combination of chronically instrumented fetal sheep and 4D flow MRI of the whole fetal liver, which allows retrospective blood flow measurement in all visible vessels as well as qualitative assessment. The applicability and usefulness of this technique is exhibited in normally grown fetal Merino sheep in mid- and late-gestation with detailed dynamic distribution of hepatic blood flow presented. The feasibility of this approach in clinical pathology is demonstrated in two growth-restricted fetuses at mid-gestation. Further exemplification of blood flow quantification is performed over major hepatic vessels. ABSTRACT Although the fetal vasculature has been demarcated and well understood for several decades, the corresponding haemodynamics permitting oxygen- and nutrient-rich blood delivery to the fetal organs has been comparatively difficult to study. We married two well-established methods: 4D flow MRI, a volumetric and dynamic blood-flow measurement technique, and chronically instrumented sheep to broadly assess fetal hepatic circulation. We performed this technique in mid- and late-gestation fetal Merino sheep under normoxemic conditions and major hepatic vasculature was segmented to quantify blood flow and related parameters. Dynamic blood flow was visualized, exhibiting an acceleration of umbilical vein blood through the ductus venosus as well as spiralling into the inferior vena cava where its stream remained separate from that of the hepatic veins and lower body. Ductus venosus changes from mid- to late-gestation included larger diameter (mid: 5.8 ± 0.9 vs. late: 7.1 ± 1.1 mm; P = 0.003) and cross-sectional area (mid: 27.1 ± 8.6 vs. late: 40.4 ± 11.8 mm2 ; P = 0.003), and lower velocity averaged over the cardiac cycle (mid: 15.7 ± 5.4 vs. late: 9.8 ± 7.0 cm s-1 ; P = 0.020). This resulted in higher magnitude blood flow (indexed to umbilical vein input) at mid-gestation in the ductus venosus (mid: 0.73 ± 0.21; late: 0.46 ± 0.21; P = 0.008). The visualization and quantification results support the further use of this technique to better understand regional blood flow changes during normal or abnormal fetal growth, as well as to observe acute haemodynamic responses to physiological challenges or drug interventions.
Collapse
Affiliation(s)
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia
| | - Brahmdeep S Saini
- Heart Centre, Hospital for Sick Children, Faculty of Medicine, Institute of Medical Science, University of Toronto
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia
| | - Sunthara R Perumal
- Preclinical Imaging and Research Laboratories, South Australian Health and Medical Research Institute
| | - Mike Seed
- Division of Cardiology, Hospital for Sick Children, Department of Paediatrics, University of Toronto
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children, Department of Medical Biophysics, University of Toronto
| |
Collapse
|
7
|
Cho SKS, Darby JRT, Saini BS, Lock MC, Holman SL, Lim JM, Perumal SR, Macgowan CK, Morrison JL, Seed M. Feasibility of ventricular volumetry by cardiovascular MRI to assess cardiac function in the fetal sheep. J Physiol 2020; 598:2557-2573. [PMID: 32378201 DOI: 10.1113/jp279054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/27/2020] [Indexed: 12/12/2022] Open
Abstract
KEY POINTS The application of fetal cardiovascular magnetic resonance imaging (CMR) to assess fetal cardiovascular physiology and cardiac function through the quantification of ventricular volumes has previously been investigated, but the approach has not yet been fully validated. Ventricular output measurements calculated from heart rate and stroke volumes (SV) of the right and left ventricles measured by ventricular volumetry (VV) exhibited a high level of agreement with phase-contrast (PC) blood flow measurements in the main pulmonary artery and ascending aorta, respectively. Ejection fraction of the right ventricle, which is lower than that of the left ventricle in postnatal subjects, was similar to the left ventricular ejection fraction in the fetus; probably due to the different loading conditions present in the fetal circulation. This study provides evidence to support the reliability of VV in the sheep fetus, providing evidence for its use in animal models of human diseases affecting the fetal circulation. ABSTRACT The application of ventricular volumetry (VV) by cardiovascular magnetic resonance imaging (CMR) in the fetus remains challenging due to the small size of the fetal heart and high heart rate. The reliability of this technique in utero has not yet been established. The aim of this study was to assess the feasibility and reliability of VV in a fetal sheep model of human pregnancy. Right and left ventricular outputs by stroke volume (SV) measured using VV were compared with 2D phase-contrast (PC) CMR measurements of blood flow in the main pulmonary artery (MPA) and ascending aorta (AAo). At 124-140 days (d) gestation, singleton bearing Merino ewes underwent CMR under general anaesthesia using fetal femoral artery catheters, implanted at 109-117d, to trigger cine steady state free precession acquisitions of ventricular short-axis stacks. The short-axis cine stacks were segmented at end-systole and end-diastole, yielding right and left ventricular SV, ejection fraction, and cardiac outputs (SV × heart rate). PC cine acquisitions of MPA and AAo were analysed to measure blood flow, which served as comparators for the right and left cardiac outputs by VV. There was good correlation and agreement between VV and PC measures of ventricular outputs with no significant bias (r2 = 0.926; P < 0.0001; Bias = -4.7 ± 10.5 ml min-1 kg-1 ; 95% limits of agreement: -15.9 to 25.2 ml min-1 kg-1 ). This study validates fetal VV by CMR in a large animal model of human pregnancy and provides preliminary reference values of fetal sheep right and left ventricles in late gestation.
Collapse
Affiliation(s)
- Steven K S Cho
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, 5001, Australia.,Division of Cardiology, Hospital for Sick Children, Toronto, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, 5001, Australia
| | - Brahmdeep S Saini
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, Hospital for Sick Children, Toronto, Canada
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, 5001, Australia
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, 5001, Australia
| | - Jessie Mei Lim
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Hospital for Sick Children, Toronto, Canada
| | - Sunthara Rajan Perumal
- Preclinical, Imaging & Research Laboratories, South Australian Health & Medical Research Institute, Adelaide, Australia
| | - Christopher K Macgowan
- Translational Medicine, Hospital for Sick Children, Toronto, Canada.,Department of Medical Biophysics, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, 5001, Australia
| | - Mike Seed
- Division of Cardiology, Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
8
|
Saini BS, Darby JRT, Portnoy S, Sun L, van Amerom J, Lock MC, Soo JY, Holman SL, Perumal SR, Kingdom JC, Sled JG, Macgowan CK, Morrison JL, Seed M. Normal human and sheep fetal vessel oxygen saturations by T2 magnetic resonance imaging. J Physiol 2020; 598:3259-3281. [PMID: 32372463 DOI: 10.1113/jp279725] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 04/30/2020] [Indexed: 12/21/2022] Open
Abstract
KEY POINTS Human fetal Doppler ultrasound and invasive blood gas measurements obtained by cordocentesis or at the time of delivery reveal similarities with sheep (an extensively used model for human fetal cardiovascular physiology). Oxygen saturation (SO2 ) measurements in human fetuses have been limited to the umbilical and scalp vessels, providing little information about normal regional SO2 differences in the fetus. Blood T2 MRI relaxometry presents a non-invasive measure of SO2 in the major fetal vessels. This study presents the first in vivo validation of fetal vessel T2 oximetry against the in vitro T2-SO2 relationship using catheterized sheep fetuses and compares the normal SO2 in the major vessels between the human and sheep fetal circulations. Human fetal vessel SO2 by T2 MRI confirms many similarities with the sheep fetal circulation and is able to demonstrate regional differences in SO2 ; in particular the significantly higher SO2 in the left versus right heart. ABSTRACT Blood T2 magnetic resonance imaging (MRI) relaxometry non-invasively measures oxygen saturation (SO2 ) in major vessels but has not been validated in fetuses in vivo. We compared the blood T2-SO2 relationship in vitro (tubes) and in vivo (vessels) in sheep, and measured SO2 across the normal human and sheep fetal circulations by T2. Singleton pregnant ewes underwent surgery to implant vascular catheters. In vitro and in vivo sheep blood T2 measurements were related to corresponding SO2 measured using a blood gas analyser, as well as relating T2 and SO2 of human fetal blood in vitro. MRI oximetry was performed in the major vessels of 30 human fetuses at 36 weeks (term, 40 weeks) and 10 fetal sheep (125 days; term, 150 days). The fidelity of in vivo fetal T2 oximetry was confirmed through comparison of in vitro and in vivo sheep blood T2-SO2 relationships (P = 0.1). SO2 was similar between human and sheep fetuses, as was the fetal oxygen extraction fraction (human, 33 ± 11%; sheep, 34 ± 7%; P = 0.798). The presence of streaming in the human fetal circulation was demonstrated by the SO2 gradient between the ascending aorta (68 ± 10%) and the main pulmonary artery (49 ± 9%; P < 0.001). Human and sheep fetal vessel MRI oximetry based on T2 is a validated approach that confirms the presence of streaming of umbilical venous blood towards the heart and brain. Streaming is important in ensuring oxygen delivery to these organs and its disruption may have important implications for organ development, especially in conditions such as congenital heart disease and fetal growth restriction.
Collapse
Affiliation(s)
- Brahmdeep S Saini
- Institute of Medical Science, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Sharon Portnoy
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada
| | - Liqun Sun
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Joshua van Amerom
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Stacey L Holman
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Sunthara R Perumal
- Preclinical Imaging and Research Laboratories, South Australian Health and Medical Research Institute, Adelaide, South Australia, 5086, Australia
| | - John C Kingdom
- Department of Obstetrics and Gynaecology, Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, Ontario, M5G 1X5, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, M5G 1E2, Canada
| | - John G Sled
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, M5G 1L7, Canada
| | - Christopher K Macgowan
- Translational Medicine, The Hospital for Sick Children, Toronto, Ontario, M5G 0A4, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Ontario, M5G 1L7, Canada
| | - Janna L Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, South Australia, 5000, Australia
| | - Mike Seed
- Institute of Medical Science, University of Toronto, Toronto, Ontario, M5S 1A8, Canada.,Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada.,Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, M5G 1E2, Canada
| |
Collapse
|
9
|
Abstract
Magnetic resonance imaging (MRI) is an appealing technology for fetal cardiovascular assessment. It can be used to visualize fetal cardiac and vascular anatomy, to quantify fetal blood flow, and to quantify fetal blood oxygen saturation and hematocrit. However, there are practical limitations to the use of conventional MRI for fetal cardiovascular assessment, including the small size and high heart rate of the human fetus, the lack of conventional cardiac gating methods to synchronize data acquisition, and the potential corruption of MRI data due to maternal respiration and unpredictable fetal movements. In this review, we discuss recent technical advances in accelerated imaging, image reconstruction, cardiac gating, and motion compensation that have enabled dynamic MRI of the fetal heart.
Collapse
|
10
|
Schrauben EM, Saini BS, Darby JRT, Soo JY, Lock MC, Stirrat E, Stortz G, Sled JG, Morrison JL, Seed M, Macgowan CK. Fetal hemodynamics and cardiac streaming assessed by 4D flow cardiovascular magnetic resonance in fetal sheep. J Cardiovasc Magn Reson 2019; 21:8. [PMID: 30661506 PMCID: PMC6340188 DOI: 10.1186/s12968-018-0512-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/04/2018] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND To date it has not been possible to obtain a comprehensive 3D assessment of fetal hemodynamics because of the technical challenges inherent in imaging small cardiac structures, movement of the fetus during data acquisition, and the difficulty of fusing data from multiple cardiac cycles when a cardiac gating signal is absent. Here we propose the combination of volumetric velocity-sensitive cardiovascular magnetic resonance imaging ("4D flow" CMR) and a specialized animal preparation (catheters to monitor fetal heart rate, anesthesia to immobilize mother and fetus) to examine fetal sheep cardiac hemodynamics in utero. METHODS Ten pregnant Merino sheep underwent surgery to implant arterial catheters in the target fetuses. Anesthetized ewes underwent 4D flow CMR with acquisition at 3 T for fetal whole-heart coverage with 1.2-1.5 mm spatial resolution and 45-62 ms temporal resolution. Flow was measured in the heart and major vessels, and particle traces were used to visualize circulatory patterns in fetal cardiovascular shunts. Conservation of mass was used to test internal 4D flow consistency, and comparison to standard 2D phase contrast (PC) CMR was performed for validation. RESULTS Streaming of blood from the ductus venosus through the foramen ovale was visualized. Flow waveforms in the major thoracic vessels and shunts displayed normal arterial and venous patterns. Combined ventricular output (CVO) was 546 mL/min per kg, and the distribution of flows (%CVO) were comparable to values obtained using other methods. Internal 4D flow consistency across 23 measurement locations was established with differences of 14.2 ± 12.1%. Compared with 2D PC CMR, 4D flow showed a strong correlation (R2 = 0.85) but underestimated flow (bias = - 21.88 mL/min per kg, p < 0.05). CONCLUSIONS The combination of fetal surgical preparation and 4D flow CMR enables characterization and quantification of complex flow patterns in utero. Visualized streaming of blood through normal physiological shunts confirms the complex mechanism of substrate delivery to the fetal heart and brain. Besides offering insight into normal physiology, this technology has the potential to qualitatively characterize complex flow patterns in congenital heart disease phenotypes in a large animal model, which can support the development of new interventions to improve outcomes in this population.
Collapse
Affiliation(s)
| | - Brahmdeep Singh Saini
- Heart Centre, Hospital for Sick Children, Toronto, Canada
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Jack R. T. Darby
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Mitchell C. Lock
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Elaine Stirrat
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - Greg Stortz
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
| | - John G. Sled
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| | - Janna L. Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Mike Seed
- Division of Cardiology, Hospital for Sick Children, Toronto, Canada
- Department of Paediatrics, University of Toronto, Toronto, Canada
| | - Christopher K. Macgowan
- Translational Medicine, Hospital for Sick Children, Toronto, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, Canada
| |
Collapse
|
11
|
Duan AQ, Darby JRT, Soo JY, Lock MC, Zhu MY, Flynn LV, Perumal SR, Macgowan CK, Selvanayagam JB, Morrison JL, Seed M. Feasibility of phase-contrast cine magnetic resonance imaging for measuring blood flow in the sheep fetus. Am J Physiol Regul Integr Comp Physiol 2017; 317:R780-R792. [PMID: 29351431 DOI: 10.1152/ajpregu.00273.2017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Phase-contrast cine MRI (PC-MRI) is the gold-standard noninvasive technique for measuring vessel blood flow and has previously been applied in the human fetal circulation. We aimed to assess the feasibility of using PC-MRI to define the distribution of the fetal circulation in sheep. Fetuses were catheterized at 119-120 days of gestation (term, 150 days) and underwent MRI at ∼123 days of gestation under isoflurane anesthesia, ventilated at a FIO2 of 1.0. PC-MRI was performed using a fetal arterial blood pressure catheter signal for cardiac triggering. Blood flows were measured in the major fetal vessels, including the main pulmonary artery, ascending and descending aorta, superior vena cava, ductus arteriosus, left and right pulmonary arteries, umbilical vein, ductus venosus, and common carotid artery and were indexed to estimated fetal weight. The combined ventricular output, pulmonary blood flow, and flow across the foramen ovale were calculated from vessel flows. Intraobserver and interobserver agreement and reproducibility was assessed. Blood flow measurements were successfully obtained in 61 out of 74 vessels (82.4%) interrogated in 9 fetuses. There was good intraobserver [R = 0.998, P < 0.0001; intraclass correlation (ICC) = 0.997] and interobserver agreement (R = 0.996, P < 0.0001; ICC = 0.996). Repeated MRI measurements showed good reproducibility (R = 0.989, P = 0.0002; ICC = 0.990). We conclude that PC-MRI using fetal catheters for gating triggers is feasible in the major vessels of late gestation fetal sheep. This approach may provide a useful new tool for assessing the circulatory characteristics of fetal sheep models of human disease, including fetal growth restriction and congenital heart disease.
Collapse
Affiliation(s)
- An Qi Duan
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jack R T Darby
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Mitchell C Lock
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Meng Yuan Zhu
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lucy V Flynn
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Sunthara Rajan Perumal
- Preclinical, Imaging, and Research Laboratories, South Australian Health and Medical Research Institute, Gilles Plains, Adelaide, Australia
| | - Christopher K Macgowan
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Division of Translational Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Janna L Morrison
- Early Origins of Adult Health Research Group, School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Mike Seed
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Duan AQ, Lock MC, Perumal SR, Darby JR, Soo JY, Selvanayagam JB, Macgowan CK, Seed M, Morrison JL. Feasibility of detecting myocardial infarction in the sheep fetus using late gadolinium enhancement CMR imaging. J Cardiovasc Magn Reson 2017; 19:69. [PMID: 28903760 PMCID: PMC5598048 DOI: 10.1186/s12968-017-0383-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 08/29/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging has enabled the accurate assessment of myocardial infarction (MI). However, LGE CMR has not been performed successfully in the fetus, where it could be useful for animal studies of interventions to promote cardiac regeneration. We believe that LGE imaging could allow us to document the presence, extent and effect of MI in utero and would thereby expand our capacity for conducting fetal sheep MI research. We therefore aimed to investigate the feasibility of using LGE to detect MI in sheep fetuses. METHODS Six sheep fetuses underwent a thoracotomy and ligation of a left anterior descending (LAD) coronary artery branch; while two fetuses underwent a sham surgery. LGE CMR was performed in a subset of fetuses immediately after the surgery and three days later. Early gadolinium enhancement (EGE) CMR was also performed in a subset of fetuses on both days. Cine imaging of the heart was performed to measure ventricular function. RESULTS The imaging performed immediately after LAD ligation revealed no evidence of infarct on LGE (n=3). Two of four infarcted fetuses (50%) showed hypoenhancement at the infarct site on the EGE images. Three days after the ligation, LGE images revealed a clear, hyper-enhanced infarct zone in four of the five infarcted fetuses (80%). No hyper-enhanced infarct zone was seen on the one sham fetus that underwent LGE CMR. No hypoenhancement could be seen in the EGE images in either the sham (n=1) or the infarcted fetus (n=1). No regional wall motion abnormalities were apparent in two of the five infarcted fetuses. CONCLUSION LGE CMR detected the MI three days after LAD ligation, but not immediately after. Using available methods, EGE imaging was less useful for detecting deficits in perfusion. Our study provides evidence for the ability of a non-invasive tool to monitor the progression of cardiac repair and damage in fetuses with MI. However, further investigation into the optimal timing of LGE and EGE scans and improvement of the sequences should be pursued with the aim of expanding our capacity to monitor cardiac regeneration after MI in fetal sheep.
Collapse
Affiliation(s)
- An Qi Duan
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King’s College Circle, Room 2374, Toronto, ON M5S 1A8 Canada
| | - Mitchell C. Lock
- Early Origins of Adult Health Research Group, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia 5000 Australia
| | - Sunthara Rajan Perumal
- Preclinical, Imaging and Research Laboratories, South Australian Health and Medical Research Institute, 101 Blacks Road, Gilles Plains, Adelaide, South Australia 5086 Australia
| | - Jack R. Darby
- Early Origins of Adult Health Research Group, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia 5000 Australia
| | - Jia Yin Soo
- Early Origins of Adult Health Research Group, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia 5000 Australia
| | - Joseph B. Selvanayagam
- Cardiac Imaging Research Group, Department of Heart Health, South Australian Health & Medical Research Institute, and Flinders University, GPO Box 2100, Adelaide, South Australia 5001 Australia
| | - Christopher K. Macgowan
- Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Room 08.9714, 686 Bay Street, Toronto, ON M5G 0A4 Canada
| | - Mike Seed
- Division of Cardiology, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| | - Janna L. Morrison
- Early Origins of Adult Health Research Group, Sansom Institute for Health Research, School of Pharmacy and Medical Sciences, University of South Australia, Frome Road, Adelaide, South Australia 5000 Australia
| |
Collapse
|
13
|
Manganaro L, Vinci V, Bernardo S, Sollazzo P, Sergi ME, Saldari M, Ventriglia F, Giancotti A, Rizzo G, Catalano C. Magnetic resonance imaging of fetal heart: anatomical and pathological findings. J Matern Fetal Neonatal Med 2014; 27:1213-9. [PMID: 24102352 DOI: 10.3109/14767058.2013.852174] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Congenital heart disease is one of the most frequent prenatal malformation representing an incidence of 5/1000 live births; moreover, it represents the first cause of death in the first year of life. There is a wide range of severity in congenital heart malformations from lesions which require no treatment such as small ventricular septal defects, to lesions which can only be treated with palliative surgery such as hypoplastic left heart syndrome. A good prenatal examination acquires great importance in order to formulate an early diagnosis and improve pregnancy management. Nowadays, echocardiography still represents the gold standard examination for fetal heart disease. However, especially when preliminary ultrasound is inconclusive, fetal MRI is considered as a third-level imaging modality. Preliminary experiences have demonstrated the validity of this reporting a diagnostic accuracy of 79%. Our article aims to outline feasibility of fetal MRI in the anatomic evaluation, the common indication to fetal MRI, its role in the characterization of congenital heart defects, and at last its main limitations.
Collapse
Affiliation(s)
- L Manganaro
- Department of Radiological Oncological and Anatomopathological Sciences, Umberto I Hospital, "Sapienza" University of Rome , Rome , Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Donofrio MT, Moon-Grady AJ, Hornberger LK, Copel JA, Sklansky MS, Abuhamad A, Cuneo BF, Huhta JC, Jonas RA, Krishnan A, Lacey S, Lee W, Michelfelder EC, Rempel GR, Silverman NH, Spray TL, Strasburger JF, Tworetzky W, Rychik J. Diagnosis and treatment of fetal cardiac disease: a scientific statement from the American Heart Association. Circulation 2014; 129:2183-242. [PMID: 24763516 DOI: 10.1161/01.cir.0000437597.44550.5d] [Citation(s) in RCA: 739] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. METHODS AND RESULTS A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin-twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. CONCLUSIONS Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.
Collapse
|
15
|
Dong SZ, Zhu M, Li F. Preliminary experience with cardiovascular magnetic resonance in evaluation of fetal cardiovascular anomalies. J Cardiovasc Magn Reson 2013; 15:40. [PMID: 23692653 PMCID: PMC3666966 DOI: 10.1186/1532-429x-15-40] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Accepted: 04/15/2013] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The cardiovascular system is the part of the fetal anatomy that most frequently suffers from congenital pathology. This study shows our preliminary experience with fetal cardiovascular magnetic resonance (CMR) to evaluate congenital cardiovascular abnormalities. METHODS Between January 2006 and June 2011, Prenatal routine obstetric ultrasound (US), echocardiography and CMR data from 68 pregnant women carrying fetuses with congenital cardiovascular anomalies were compared with postnatal diagnoses (postnatal imagings, surgery and autopsy). All prenatal CMR was performed at 1.5 T. Imaging sequences included steady-state free-precession (SSFP) sequences, real-time SSFP and single-shot turbo spin echo (SSTSE) sequences. The images were analyzed with an anatomic segmental approach by two radiologists. RESULTS Fetal CMR yielded the same diagnosis as postnatal findings in 79% (54/68) of patients. The diagnostic sensitivity of routine obstetric US for cardiac anomalies was 46% (31/68). The diagnostic sensitivity of fetal echocardiographic examination by a fetal cardiac specialist was 82% (56/68). In 2 (3%) of 68 cases, diagnoses with both echocardiography and CMR were incorrect when compared with postnatal diagnosis. In ten (15%) cases, diagnosis at echocardiography was incorrect and that at CMR was correct. In twelve (18%) cases, diagnosis at echocardiography was correct and that at CMR was incorrect. Ten cases missed or misdiagnosed by echocardiography but correctly diagnosed by fetal CMR included asplenia syndrome (n = 2), interrupted inferior vena cava of polysplenia syndrome (n = 1), tricuspid incompetence (n = 1), double outlet right ventricle (n = 2), double aortic arch (n = 1), right pulmonary artery hypoplasia (n = 1), right-sided aortic arch of tetralogy of Fallot (n = 1) and hypoplastic left heart syndrome of a twin fetus (n = 1). CONCLUSION Fetal CMR is a promising diagnostic tool for assessment of congenital cardiovascular abnormalities, especially in situations that limit echocardiography.
Collapse
Affiliation(s)
- Su-Zhen Dong
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Ming Zhu
- Department of Radiology, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| | - Fen Li
- Department of Cardiology, Shanghai Children’s Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
| |
Collapse
|
16
|
Di Cesare E, Cademartiri F, Carbone I, Carriero A, Centonze M, De Cobelli F, De Rosa R, Di Renzi P, Esposito A, Faletti R, Fattori R, Francone M, Giovagnoni A, La Grutta L, Ligabue G, Lovato L, Marano R, Midiri M, Romagnoli A, Russo V, Sardanelli F, Natale L, Bogaert J, De Roos A. [Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]. Radiol Med 2012. [PMID: 23184241 DOI: 10.1007/s11547-012-0899-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.
Collapse
Affiliation(s)
- E Di Cesare
- Dipartimento di Scienze Cliniche Applicate e Biotecnologiche, Università di L'Aquila, L'Aquila, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Votino C, Jani J, Damry N, Dessy H, Kang X, Cos T, Divano L, Foulon W, De Mey J, Cannie M. Magnetic resonance imaging in the normal fetal heart and in congenital heart disease. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 39:322-329. [PMID: 21837757 DOI: 10.1002/uog.10061] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/21/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate prospectively the feasibility of magnetic resonance imaging (MRI) for assessment of the fetal heart for congenital heart disease (CHD). METHODS This was a cross-sectional study, including 66 fetuses with a normal heart and 40 with CHD. The fetal heart was examined on MRI using axial steady-state free precession (SSFP) sequences. Regression analysis was used to investigate the effect on the ability to visualize cardiac anatomy of gestational age at examination, maternal body mass index, presence of fetal cardiac abnormality, fetal movements, fetal lie and twinning. The sensitivity and specificity of detecting cardiac defects were calculated. RESULTS The four-chamber view was visualized in 98.1% of fetuses. The sensitivity of detecting a cardiac defect on the four-chamber view was 88% and the specificity 96%. The ability to visualize the left and right outflow tracts was only influenced by the presence of fetal movements: for the left outflow tract 94.4 vs. 50.0% visualization and for the right outflow tract 92.6 vs. 53.8% visualization without and with fetal movements, respectively. The sensitivity of detecting a cardiac defect of the left outflow tract was 63% and the specificity 100%, while sensitivity and specificity were 59 and 97%, respectively, for the right outflow tract. CONCLUSIONS Despite the use of SSFP sequences, MRI in the fetal heart remains of limited value. It can only be used as a second-line approach for abnormalities of the four-chamber view suspected at prenatal ultrasound.
Collapse
Affiliation(s)
- C Votino
- Department of Obstetrics and Gynaecology, University Hospital Brugmann, Brussels, Belgium
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Yamamura J, Kopp I, Frisch M, Fischer R, Valett K, Hecher K, Adam G, Wedegärtner U. Cardiac MRI of the fetal heart using a novel triggering method: initial results in an animal model. J Magn Reson Imaging 2012; 35:1071-6. [PMID: 22246623 DOI: 10.1002/jmri.23541] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 11/22/2011] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To investigate MRI of the fetal heart by way of a novel triggering method with the use of an MR-compatible cardiotocography (CTG) in an animal model. MATERIALS AND METHODS Fetal cardiac MRI was performed on four pregnant ewes on a 1.5 Tesla (T) MR system. A CTG was rendered MR compatible and its signal was used for the triggering of the fetal heart to perform cardiac cine MRI of the fetal heart with maternal free-breathing with cine steady-state free precession. The left ventricular volume and function were measured from the short-axis (view). The image quality of anatomical structures was assessed. RESULTS All cardiac valves and the foramen ovale could be visualized. Myocardial contraction was depicted in cine sequences. The average blood volume at the end systole was 1.7 mL (SD ± 0.12). The average volume at the end diastole was 4.6 mL (± 0.4); thus the average stroke volumes of the left ventricle were 2.87 mL (± 0.31) with ejection fractions of 60.53% (± 4.17). CONCLUSION The newly developed MR compatible CTG could be used as a tool for cardiac triggering method of the fetal heart. This novel device might help fetal cardiac MRI technology in the future.
Collapse
Affiliation(s)
- Jin Yamamura
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Buhk JH, Frisch M, Yamamura J, Graessner J, Adam G, Wedegärtner U. High-resolution in utero 3D MR imaging of inner ear microstructures in fetal sheep. AJNR Am J Neuroradiol 2011; 32:2043-6. [PMID: 22033721 DOI: 10.3174/ajnr.a2736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Developmental inner ear abnormalities can occur due to embryopathies as well as in the context of syndromal diseases like the CHARGE association. In severe cases, an early and definite in utero diagnosis is important for decision-making; here, fetal MR imaging can be a helpful tool. We present results of performing high-resolution MR imaging of the inner ear structures of fetal sheep in vivo. METHODS AND MATERIALS Six ewes carrying singleton fetuses (mean gestational age, 120 days) were examined under general anesthesia at 1.5T. A 3D true FISP sequence with isotropic voxel size (0.7 mm) was applied; acquisition time was 2:35 minutes. For a standard of reference, 1 stillborn lamb of equivalent gestation age was examined. Image analysis was performed in consensus by 2 radiologists regarding the depiction of anatomic landmarks on a 5-point scale. Motion artifacts were quantified on a 3-point scale. RESULTS The turns and modiolus of the cochlea as well as the origins of all 3 semicircular canals of the vestibular system of both sides could be reliably identified in every animal. Motion artifacts due to maternal breathing excursions or movements of the fetus were minimal. In case of breech presentation, the ventilation of the ewe had to be paused during the image acquisition to achieve acceptable results. CONCLUSIONS High-resolution intrauterine MR imaging of the inner ear microstructures in an animal model is feasible. However, the acquisition time of the sequence applied is still too long to perform such measurement in a clinical setting.
Collapse
Affiliation(s)
- J-H Buhk
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany.
| | | | | | | | | | | |
Collapse
|
20
|
Yamamura J, Schnackenburg B, Kooijmann H, Frisch M, Hecher K, Adam G, Wedegärtner U. Magnetic resonance angiography of fetal vessels: feasibility study in the sheep fetus. Jpn J Radiol 2010; 28:720-6. [PMID: 21191736 DOI: 10.1007/s11604-010-0498-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Accepted: 07/21/2010] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to perform fetal magnetic resonance angiography (MRA) in utero in a sheep model. MATERIAL AND METHODS Images of the great vessels, the heart, and the tracheal tree were performed on four pregnant ewes with a 1.5-T scanner (Philips Medical Systems, Best, The Netherlands). MRA was achieved in utero using a nontriggered free-breathing three-dimensional balanced fast field echo (FFE) technique. All obtained MRA images were evaluated in consensus on a three-point scale by two radiologists with 9 and 4 years of experience in fetal MRI, respectively. RESULTS The fetal heart frequencies were between 130 and 160 bpm. The aorta from the aortic bulb to the bifurcation as well as some of the main aortic branches could be depicted. The pulmonary trunk and arteries, the superior and inferior caval veins, and the subsegmental branches of the trachea could also be visualized. CONCLUSION The nontriggered MRA of the fetal great vessels with images of the tracheal tree allowed an excellent evaluation of anatomical structures.
Collapse
Affiliation(s)
- Jin Yamamura
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, 52 Martinistrasse, Hamburg, 20246, Germany.
| | | | | | | | | | | | | |
Collapse
|
21
|
Yamamura J, Frisch M, Ecker H, Graessner J, Hecher K, Adam G, Wedegärtner U. Self-gating MR imaging of the fetal heart: comparison with real cardiac triggering. Eur Radiol 2010; 21:142-9. [PMID: 20676652 DOI: 10.1007/s00330-010-1911-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 06/04/2010] [Accepted: 06/14/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the self-gating technique for MR imaging of the fetal heart in a sheep model. MATERIAL AND METHODS MR images of 6 fetal sheep heart were obtained at 1.5 T. For self-gating MRI of the fetal heart a cine SSFP in short axis, two and four chamber view was used. Self-gated images were compared with real cardiac triggered MR images (pulse-wave triggering). MRI of the fetal heart was performed using both techniques simultaneously. Image quality was assessed and the left ventricular volume and function were measured and compared. RESULTS Compared with pulse-wave triggering, the self-gating technique produced slightly inferior images with artifacts. Especially the atrial septum could not be so clearly depicted. The contraction of the fetal heart was shown in cine sequences in both techniques. The average blood volumes could be measured with both techniques with no significant difference: at end-systole 3.1 ml (SD±0.2), at end-diastole 4.9 ml (±0.2), with ejection fractions at 38.6%, respectively 39%. CONCLUSION Both self-gating and pulse-wave triggered cardiac MRI of the fetal heart allowed the evaluation of anatomical structures and functional information. Images obtained by self-gating technique were slightly inferior than the pulse-wave triggered MRI.
Collapse
Affiliation(s)
- Jin Yamamura
- Department of Diagnostic and Interventional Radiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | | | | | | | | | | | | |
Collapse
|
22
|
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]
|