Severe tricuspid regurgitation simulating pulmonary atresia in the fetus

Recipient Twin Circular Shunt Physiology Before Fetal Laser Surgery: Survival and Risks for Postnatal Right Ventricular Outflow Tract Obstruction

OBJECTIVES

To evaluate risk for congenital heart disease (CHD) in recipient twins with circular shunt physiology (CSP).

METHODS

This prospective study enrolled twin-twin transfusion syndrome (TTTS) cases from 2006 to 2015. Fetal echocardiography (FE) was performed before laser surgery when cardiac involvement was suspected. Diagnosis of recipient twin CSP required tricuspid and pulmonary regurgitation, right ventricular dysfunction, and flow reversal in the ductus arteriosus. Outcomes were assessed at 30 days after birth.

RESULTS

Of the 496 TTTS pregnancies, 20 (4%) met the criteria for CSP. Among those born alive, who had documented cardiac outcomes (n = 457), patients with CSP were more likely to have CHD, specifically right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 22 of 439 [5.0%], odd ratio [OR] 7.29, 95% confidence interval [CI] 2.05-24.72, P = .0025). Of the recipient twins with preoperative FE (n = 259, 52%) who were born alive and had documented cardiac outcomes (n = 242), those with CSP were still more likely to have right ventricular outflow tract obstruction (5 of 18 [27.8%] versus 14 of 224 [6.3%], OR 5.77, CI 1.54-20.92, P = .0077). With both analyses, twins with CSP had higher Quintero stage, but similar patient characteristics and 30-day mortality compared with those without CSP. Subgroup analyses of the CSP cohort identified no differences in preoperative characteristics or FE findings predictive of CHD.

CONCLUSIONS

Recipient twins with preoperative CSP were at increased risk for postnatal right ventricular outflow tract obstruction, but appeared to have comparable survival after fetal laser surgery despite these dramatic pathophysiological prenatal findings. Preoperative FE in TTTS remains important for prediction of postnatal CHD.

Ebstein's anomaly and tricuspid valve dysplasia: prognosis after diagnosis in utero

Tricuspid valve malformation is a rare congenital heart disease. Prenatal diagnosis of Ebstein's anomaly (EA) and tricuspid valve dysplasia (TVD) is associated with high mortality. There are conflicting reports concerning accurate prognostication after diagnosis in utero. The aim of our study was to assess prognostic factors based on our experience. We reviewed 37 fetuses between 1984 and June 2010 comprising 26 cases of EA and 11 cases of TVD. There were 10 terminations, 5 intrauterine deaths, 8 neonatal deaths, and 14 survivors. We found that the major prognostic factor for outcome was the flow pattern through the pulmonary valve on the first echocardiogram. Retrograde flow was strongly correlated with fetal or neonatal death (p = 8 × 10(-5)), and anterograde flow predicted good outcome (p = 8 × 10(-5)). In contrast, cardiothoracic indexes, right to left-ventricular ratio, and Celermajer index were not useful prognostic markers. The Simpson Andrews Sharland score, which was more complex, was well correlated with our series. Flow through the pulmonary valve on the first echocardiogram is a simple and excellent prognostic factor when major tricuspid valve disease is diagnosed in utero. Fetuses should be monitored throughout pregnancy, particularly those with retrograde ductus arteriosus, because several hemodynamic factors may worsen the prognosis.

Intrauterine hemodynamics of tricuspid valve dysplasia in a growth-restricted infant

We present a case of fetal tricuspid valve dysplasia, which was diagnosed at 22 weeks of gestation during a routine obstetrical examination. Serial fetal echocardiographic evaluation revealed progressive right ventricular outflow tract obstruction and persistent cardiomegaly. A female infant weighing 1,916 g was delivered by elective cesarean section at 38 weeks of gestation. Longstanding compression of the fetal lungs secondary to the persistent cardiomegaly resulted in severe respiratory distress and cyanosis immediately after birth. Although, mechanical ventilation and continuous infusion of prostaglandin were instituted, the infant died of respiratory failure at 21 days of age. During the pregnancy, the fetus exhibited intrauterine growth restriction, but hydrops did not occur. In regard to the fetal hemodynamics in this cardiac anomaly, transatrial communication is essential for fetal survival. The diameter of the fossa ovalis, which is a marker of transtrial blood flow, was adequate in this case. However, marked enlargement of the right heart associated with regurgitation interfered with left ventricular filling and output, which resulted in restriction of the combined ventricular output and intrauterine fetal growth restriction.

Sonographic features of Ebstein anomaly associated with hydrops fetalis: a report of two cases

Ebstein anomaly, an abnormally low insertion of the tricuspid valve, occurs in 0.5% of patients with congenital heart disease. In rare cases, this disorder may be complicated by congestive heart failure in utero and hydrops fetalis. This article reports the prenatal sonographic features of 2 cases of Ebstein anomaly associated with hydrops fetalis. In both cases, fetal echocardiography was performed at 34 weeks of gestation. The 4-chamber view showed fetal cardiomegaly and pericardial effusion. In both cases, the annular attachment of the tricuspid valve leaflets was difficult to demonstrate and so distal that it could easily be confused with papillary muscle in the right ventricular wall. Poor fetal cardiac hemodynamics with severe tricuspid regurgitation was demonstrated by pulsed Doppler imaging. Pulmonary regurgitation was also clearly demonstrated in both cases. Preterm delivery with stillbirth occurred in both cases. Autopsies confirmed the very distal displacement of the tricuspid valve insertion, close to the apex, and enlargement of the right atrium.

Prenatal cardiovascular manifestations in the twin-to-twin transfusion syndrome recipients and the impact of therapeutic amnioreduction

OBJECTIVE

We evaluated the cardiovascular pathologic condition in the recipient twin in twin-to-twin transfusion syndrome and the influence of amnioreduction.

STUDY DESIGN

Fetal echocardiograms and medical records of 54 pregnancies that were complicated by twin-to-twin transfusion syndrome were reviewed. Recipient twin right and left ventricular wall thickness, diameters, systolic and diastolic function, valve regurgitation, and structural cardiac defects were assessed at examination and after amnioreduction.

RESULTS

At examination (n = 28 pregnancies), cardiomegaly because of right ventricular and/or left ventricular hypertrophy was observed in 58% of recipient twins, and biventricular hypertrophy was observed in 33% of recipient twins, without ventricular dilation. Biventricular diastolic dysfunction was present in two thirds of recipient twins, and right ventricular systolic dysfunction and significant atrioventricular valve regurgitation was observed in one third of recipient twins. Serial assessment (n = 21 pregnancies) revealed progressive biventricular hypertrophy and right ventricular systolic and biventricular diastolic dysfunction in most recipient twins. Steeper progression of hypertrophy, diastolic dysfunction, and structural or functional right ventricular outflow disease (20% incidence) were associated with an increased perinatal mortality rate.

CONCLUSION

In twin-to-twin transfusion syndrome, the recipient twin has progressive biventricular hypertrophy with predominant right ventricular systolic and biventricular diastolic dysfunction. Despite amnioreduction, the cardiovascular disease persists and even progresses in many recipient twins.

Prenatal diagnosis of severe tricuspid insufficiency in Ebstein's anomaly with pulmonary atresia and intact ventricular septum: a case report

Pulmonary atresia with intact ventricular septum is an uncommon congenital cardiac anomaly which very often present varying degrees of downward displacement and dysplasia of the tricuspid valve. A 23-year-old woman was referred at 23 weeks' gestation because of fetal cardiomegaly detected by routine ultrasonography. Ebstein's anomaly with pulmonary atresia was diagnosed by fetal echocardiography. On pulsed Doppler examination, a severe tricuspid regurgitation was detected. Pulmonary atresia was suspected, as forward flow was not detected into pulmonary artery. The fetus was terminated at 25 weeks. At the postmorterm examination Ebstein's anomaly with pulmonary atresia and intact ventricular septum were confirmed. The finding of right atrial enlargement on an early sonogram should prompt the search for tricuspid valve abnormalities with tricuspid regurgitation and the presence or development of pulmonary atresia or stenosis. With the information provided, early detection of tricuspid valve disease should be possible so that the option of therapeutic abortion can be offered.

Ebstein's anomaly: presentation and outcome from fetus to adult

OBJECTIVES

This study was conducted to investigate the presentation and outcome of patients with Ebstein's anomaly of the tricuspid valve.

BACKGROUND

Ebstin's anomaly may present at any age and has a highly variable clinical course. Previous natural history studies have been based on clinical and angiographic diagnosis and have included mainly older children and adults. Echocardiography, however, has facilitated fetal and neonatal diagnosis so that the natural history needs to be redefined.

METHODS

We reviewed 220 cases of Ebstein's anomaly presenting from fetal to adult life between 1958 and 1991, with 1 to 34 years of follow-up.

RESULTS

The most common presentation in each age group was abnormal routine prenatal scan for fetuses (86%), cyanosis for neonates (74%), heart failure for infants (43%), incidental murmur for children (63%) and arrhythmia for adolescents and adults (42%). Early presentation was frequently associated with other cardiac lesions, usually pulmonary stenosis or atresia. Surgery was undertaken at some stage in 86 (39%) of the 220 patients. Actuarial survival for all liveborn patients was 67% at 1 year and 59% at 10 years. There were 58 deaths, including 26 from heart failure, 19 perioperative and 8 sudden. Predictors of death included echocardiographic grade of severity at presentation (relative risk 2.7 for each increase in grade, 95% confidence limits 1.6 to 4.6), fetal presentation (6.9, confidence limits 1.6 to 16.5) and right ventricular outflow tract obstruction (2.1, confidence limits 1.1 to 4.4). Morbidity was mainly related to arrhythmias and late hemodynamic deterioration. Of 155 survivors, 129 (83%) were in functional class 1 and 104 (67%) were receiving no medical therapy.

CONCLUSIONS

In Ebstein's anomaly, fetal and neonatal presentation is associated with a poor outcome and can be predicted by the echocardiographic appearance and presence of associated lesions. In older children and adults, incidental findings and arrhythmia are common and the long-term outcome is superior.

Tricuspid valve dysplasia or displacement in intrauterine life

In 450 cases of structural heart disease diagnosed prenatally, 38 fetuses (8.5%) had either a dysplastic or a displaced tricuspid valve. The tricuspid valve was dysplastic in 22 fetuses, all of which had evidence of tricuspid regurgitation resulting in right atrial dilation and increased cardiothoracic ratio. An associated abnormality of the pulmonary valve occurred in 16 fetuses. The remaining 16 fetuses had Ebstein's malformation, 14 with evidence of tricuspid incompetence at presentation and 10 with an associated abnormality of the pulmonary valve. Of the 38 cases, the pregnancy was interrupted in 17, spontaneous intrauterine fetal death occurred in 8, 11 infants died postnatally and 2 infants are still alive; additional abnormalities were found in 8 cases (chromosomal anomalies in 2, ventricular septal defects in 2, corrected transposition in 2, the Chiari malformation in 2, supraventricular tachycardia in 1 case and coarctation of the aorta in 1). Fetuses with severe abnormalities are selected for fetal echocardiography by the four chamber screening program and a high rate of natural loss both in intrauterine life and immediately after birth was observed in the 21 cases in which pregnancy was continued. This would explain the higher incidence of tricuspid valve disease in our prenatal compared with postnatal series. Although increased cardiothoracic ratio and associated lesions of the right ventricular outflow tract contribute to the poor outcome in the cases detected prenatally, the absence of these features does not always indicate a good prognosis because progression of disease can occur with advancing gestational age. No absolute measurement or single echocardiographic feature emerged as a consistent predictive factor of prognosis.

Tricuspid valve disease with significant tricuspid insufficiency in the fetus: diagnosis and outcome

The echocardiographic studies and clinical course of 27 fetuses (mean gestational age 26.9 weeks) diagnosed in utero with tricuspid valve disease and significant tricuspid regurgitation were reviewed. The diagnosis of Ebstein's anomaly was made in 17 of the fetuses, 7 had tricuspid valve dysplasia with poorly developed but normally attached leaflets and 2 had an unguarded tricuspid valve orifice with little or no identifiable tricuspid tissue. One fetus was excluded from data analysis because a more complex heart lesion was documented at autopsy. All fetuses had massive right atrial dilation and most who were serially studied had progressive right-sided cardiomegaly. Hydrops fetalis was found in six cases and atrial flutter in five. Associated cardiac lesions included pulmonary stenosis in five cases and pulmonary atresia in six. Four fetuses with normal forward pulmonary artery flow at the initial examination were found at subsequent study to have retrograde pulmonary artery and ductal flow in association with the development of pulmonary stenosis (n = 1) and pulmonary atresia (n = 3). On review of the clinical course of the 23 fetuses (excluding 3 with elective abortion), 48% of the fetuses died in utero and 35% who were liveborn died despite vigorous medical and, when necessary, surgical management, many of whom had severe congestive heart failure. Of the four infants who survived the neonatal period, three had a benign neonatal course, all of whom were diagnosed with mild to moderate Ebstein's anomaly; only one had pulmonary outflow obstruction. An additional finding at autopsy was significant lung hypoplasia documented in 10 of 19 autopsy reports.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic diagnosis of fetal heart defects in mid trimester

One hundred and thirty five consecutive fetuses of between 16 and 23 weeks' gestation that were considered to be at high risk of having structural heart defects were examined prospectively to determine the reliability of echocardiography for diagnosing such defects in mid trimester. Each echocardiogram was done in a standard manner and cardiac anatomy was analysed segmentally. Twelve fetuses were excluded from analysis because of lack of follow up. Of the remaining 123 fetuses, 109 had no evidence of heart disease when followed up. In this group the prenatal echocardiogram was normal in 105 and technically inadequate in four; thus there were no false positive diagnoses of heart disease in fetuses subsequently shown to have normal hearts. Fourteen had heart defects at follow up. The serious defect was correctly diagnosed prenatally in 10 of 14 cases, whereas in the other four the prenatal echocardiogram was considered normal. Some errors were made in diagnosing associated segmental defects particularly if the heart disease was complicated. Therapeutic abortion was carried out in seven cases; in five of the fetuses the prenatally diagnosed heart defect was the sole or an important contributing reason for the abortion. We conclude that echocardiography is a reliable method for diagnosing many heart defects in the mid trimester.