Premature closure of the foramen ovale associated with aortic stenosis, left ventricular dilation with thrombus, and early mortality

Case report: Active clinical manifestation of endocardial fibroelastosis in adolescence in a patient with mitral and aortic obstruction–histologic presence of endothelial-to-mesenchymal transformation

This is the first description of active clinical manifestation of endocardial fibroelastosis (EFE) and remodeling of the endocardium via endothelial-to-mesenchymal transformation (EndMT) in an adolescent with Shone’s variant hypoplastic left heart complex (HLHC) and a genetic heterozygous ABL1 variant. While EFE has not been typically associated HLHC or Shone’s syndrome, in this patient flow alterations in the left ventricle (LV), combined with genetic alterations of intrinsic EndMT pathways led to active clinical manifestation of EFE in adolescence. This case emphasizes that new therapies for EFE might need to focus on molecular factors influenced by intrinsic and extrinsic stimuli of EndMT.

The Accelerated Right Ventricular Failure in Fetal Anemia in the Presence of Restrictive Foramen Ovale

Objective: To describe serious hemodynamic changes secondary to anemia in the case of restrictive foramen ovale (FO). Case: A 43-year-old pregnant woman, G4P0030, underwent fetal echocardiography at 35 weeks of gestation and was found to have (1) restrictive FO; (2) poor right ventricular function; (3) unbalanced hemodynamics; (4) fetal anemia (high MCA-PSV and hepatosplenomegaly). Acid-elution test indicated feto-maternal hemorrhage. Cesarean section was performed for postnatal blood transfusion. Nevertheless, the newborn developed heart failure and died after partial blood exchanges. Conclusions: Insights gained from this study are as follows: (1) Restrictive FO in structurally normal hearts can modify fetal response to anemia differently, by unequally distributing blood volume, leading to much more deteriorating right ventricular function. (2) To make decisions for intrauterine or extrauterine treatment in cases of anemia-associated heart failure, several factors must be taken into account such as gestational age, fetal cardiac function, and placental function. Because of the hyperdynamic state of newborns immediately after birth, delivery can deteriorate the compromised heart to irreversible failure. Intrauterine transfusion for a well-prepared heart just before delivery may be the best option since the baby should be well oxygenated at the time of delivery.

Clinical features and echocardiographic findings of isolated foramen ovale restriction in foetuses

Isolated restrictive foramen ovale (rFO) without complex heart defects is a rare pathology. There may be difficulties in managing this situation, which can lead to right heart enlargement, tricuspid regurgitation and hydrops findings in the foetus. We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of isolated rFO. Nine patients with neonatal echocardiographic examination were included in the study. In 8 (88.8%) patients, it was stated that a decision to give birth should be made at the time of presentation. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.IMPACT STATEMENTWhat is already known on this subject? The data about the prenatal diagnosis of isolated rFO is limited.What the results of this study add? We conducted a retrospective analysis of 8451 foetuses. 7883 (93.2%) foetuses had a structurally normal heart or minor heart disease, 18 (0.22%) of which had a diagnosis of rFO. Nıne patients with foetal and postnatal follow-up and echocardiographic findings were examined in the study. The group's median gestational age at admission was 35.0 weeks (range: 27.0-39.0 weeks). The delivery decision was made in 8 (88.8%) patients at the time of admission. Evaluating postpartum echocardiographic examinations, 7 (77.7%) patients had normal or minor defects. Additionally, one patient was diagnosed with cardiomyopathy, and the other patient was diagnosed with functional pulmonary atresia. No death occurred in any foetus during follow-up.What the implications are of these findings for clinical practice and/or further research? Isolated rFO, a rare condition in the foetus, is generally well-tolerated in foetal life. However, the right heart enlargement, tricuspid regurgitation, or hydrops findings can be seen in patients. The decision of delivery made at the right time during follow-up is critical to determine the prognosis.

Evaluation of fetal foramen ovale blood flow by pulsed Doppler ultrasonography combined with spatiotemporal image correlation : To define the normal reference range of fetal foramen ovale blood volume for each gestational age: a cross-sectional study

Objective

The objective of this study was to determine fetal foramen ovale blood flow utilizing pulsed Doppler combined with spatiotemporal image correlation.

Methods

A cross-sectional study was performed in 440 normal fetuses between 20 and 40 weeks of gestation. In order to calculate foramen ovale blood flow, the foramen ovale flow velocity–time integral was obtained by pulsed Doppler ultrasonography, and the foramen ovale area was measured by using spatiotemporal image correlation rendering mode. Foramen ovale blood flow was calculated as the product of the foramen ovale area and the velocity–time integral.

Results

Gestational age-specific reference ranges are given for the absolute blood flow (ml/min) of foramen ovale, showing an exponential increase from 20 to 30 weeks of gestation, and a flat growth trend during the last trimester, while the weight-indexed flow (ml/min/kg) of foramen ovale decreased significantly. The median weight-indexed foramen ovale blood flow was 320.82 ml/min/kg (mean 319.1 ml/min/kg; SD 106.33 ml/min/kg).

Conclusions

The reference range for fetal foramen ovale blood flow was determined from 20 to 40 weeks of gestation. The present data show that the volume of foramen ovale blood flow might have a limited capacity to increase during the last trimester.

Patent Foramen Ovale in Fetal Life, Infancy and Childhood

A patent foramen ovale (PFO) is a common, incidental echocardiographic finding in otherwise healthy and asymptomatic infants and children. However, a variety of clinical conditions have been ascribed to the presence of a PFO in childhood, such as cryptogenic stroke, platypnea-orthodeoxia syndrome, decompression sickness and migraine, although the data on these are controversial and sometimes contradictory. This review discusses embryology and correlation with post-natal anatomy, anatomical variations of the atrial septum, diagnostic modalities in special circumstances of PFO associated clinical syndromes, and the role of PFO in congenital heart disease, pulmonary hypertension, dilated cardiomyopathy and heart failure in children who require an extracorporeal membrane oxygenator or ventricular assist device as life support.

Induction of left ventricular hypoplasia by occluding the foramen ovale in the fetal lamb

Disturbed fetal haemodynamics often affects cardiac development and leads to congenital cardiac defects. Reduced left ventricular (LV) preload in the fetus may result in hypoplastic LV, mitral and aortic valve, mimicking a moderate form of hypoplastic left heart complex. We aimed to induce LV hypoplasia by occluding the foramen ovale (FO) to reduce LV preload in the fetal sheep heart, using percutaneous trans-hepatic catheterisation. Under maternal anaesthesia and ultrasound guidance, hepatic venous puncture was performed in six fetal lambs (0.7–0.75 gestation). A coronary guidewire was advanced into the fetal inferior vena cava, right and left atrium. A self-expandable stent was positioned across the FO. An Amplatzer Duct Occluder was anchored within the stent for FO occlusion. Euthanasia and post-mortem examination was performed after 3 weeks. Nine fetuses were used as age-matched controls. Morphometric measurements and cardiac histopathology were performed. Compared with controls, fetal hearts with occluded FO had smaller LV chamber, smaller mitral and aortic valves, lower LV-to-RV ratio in ventricular weight and wall volume, and lower number of LV cardiomyocyte nuclei. We conclude that fetal FO occlusion leads to a phenotype simulating LV hypoplasia. This large animal model may be useful for understanding and devising therapies for LV hypoplasia.

Hypoplastic left heart syndrome secondary to intrauterine rhabdomyoma necessitating single ventricle palliation

Rhabdomyoma, a benign hamartomatous tumor of the cardiac embryonic myocyte, is the most common intrauterine cardiac tumor and accounts for 0.12% of prenatal fetal studies. Fetal cardiac rhabdomyomas increase in size during second and early third trimester and spontaneously regress postnatally. The clinical presentation is usually benign, however, compromise of the ventricular outflow tract leading to decreased cardiac output and fetal death have been reported. We present a case of large cardiac rhabdomyoma in a fetus that might have caused complete left ventricular outflow tract obstruction and development of hypoplastic left heart syndrome (HLHS) necessitating postnatal single ventricle palliation therapy. The clinical course and outcomes of prenatally diagnosed cardiac rhabdomyoma are reviewed and theories of the development of hypoplastic left heart syndrome are explored.

The Pathological Spectrum of Left-Ventricular Hypoplasia

Left-ventricular (LV) hypoplasia encompasses a range of LV sizes, varying from a mildly underdeveloped, but functionally adequate, chamber to the miniscule, barely perceptible LV cavity seen in hypoplastic left-heart syndrome. Associated malformations include obstructive lesions of LV inflow, outflow, and the aortic arch, often in combination. Repair of complex combinations and/or severe LV hypoplasia usually results in a single-ventricle anatomy with the right ventricle serving as the systemic ventricle. New therapeutic interventions, including fetal procedures, are expanding the spectrum of lesions and LV sizes that may be amenable to a biventricular repair. These surgical considerations place renewed emphasis on understanding the anatomical features associated with LV hypoplasia. This review details pathological features of the full spectrum of LV hypoplasia, particularly those with borderline severe hypoplasia. Primary defining lesions are described as well as additional lesions that may affect clinical symptoms, surgical repair, and long-term outcome.

Premature closure of the foramen ovale secondary to congenital aortic valvular stenosis in a stillborn

Premature closure of the foramen ovale is a rare and deleterious condition that can occur as an isolated defect or in association with other congenital and cardiovascular anomalies. We report on the pathologic findings in a 22-week stillborn male fetus with premature closure of the foramen ovale, severe aortic valve stenosis, cardiomegaly, intact atrial and ventricular septa, hypoplasia of the ascending aorta, and hypoplastic aortic arch with a preductal coarctation ridge. To the best of our knowledge, this is only the second report on this rare constellation of complex congenital cardiac defects.

Late clinical manifestations of mitral valve disease and severe pulmonary hypertension in a patient diagnosed with premature closure of foramen ovale during fetal life

BACKGROUND

The patency of foramen ovale (FO) in fetal circulation is very important, and premature closure of FO could be associated with several pathological conditions.

METHODS

We report a patient in whom premature closure of FO in fetal life was associated with late clinical onset of mitral valve stenosis and subsequent development of irreversible pulmonary hypertension (PH).

RESULTS

The patient showed persistent PH after birth, which completely regressed at the age of 8 months. However, the patient developed heart failure due to mitral valve lesions (hammock valve) at the age of 11 months and underwent artificial valve replacement. The patient subsequently developed severe PH, which was refractory to anti-PH therapy with sildenafil and bosentan in addition to home oxygen.

CONCLUSIONS

This case illustrates that mitral stenosis can be overlooked during early neonatal life, and thus emphasizes the need for close follow-up for potential existence of mitral stenosis and later clinical manifestation in patients with premature FO closure even when initial careful examination of the mitral valves does not indicate any abnormalities. In addition, premature closure of FO could cause pulmonary vascular disease, which may lead to later development of irreversible PH.

Giant aneurysm of the atrial septum associated with premature closure of foramen ovale

Premature closure or restriction of foramen ovale (PCFO) is a rare congenital anomaly that can lead to a wide spectrum of cardiac malformations. This spectrum of secondary malformations appears to depend on the gestational timing of closure of the foramen ovale and to the degree of restriction. Earlier in the gestation, closure of the foramen has been associated with severe hypoplasia of the left ventricle whereas later closure has been associated with right heart failure and rarely with the formation of an aneurysm of the atrial septum. We describe the case of a 1 day old infant in whom PCFO resulted in severe right heart failure in addition to the formation of a giant atrial septal aneurysm.