Transient neonatal tricuspid regurgitation: possible relation with premature closure of the ductus arteriosus

Severe tricuspid regurgitation 14 years after diagnosis of “transient neonatal tricuspid regurgitation”

A 14 year old girl presented with severe tricuspid regurgitation after she was diagnosed with “transient tricuspid regurgitation of the newborn”. In the neonatal period she had presented with severe tricuspid regurgitation without an obvious underlying anatomical cause. This spontaneously regressed during the first months of life. She was dismissed from follow up at the age of 5 years after complete normalisation of the clinical and echocardiographic examination. The subsequent evolution and management of the patient, as well as the possible pathogenesis responsible for the unusual clinical course, is discussed. This case stresses the importance of long term follow up of patients with transient tricuspid regurgitation.

Reference ranges for two-dimensional echocardiographic examination of the fetal ductus arteriosus

OBJECTIVES

To establish reference ranges for 2D-echocardiographic examination of the fetal ductus arteriosus and its relationship to the main pulmonary artery and the aorta.

METHODS

A prospective cross-sectional echocardiographic study was performed in 222 normal fetuses from 13 to 41 weeks of gestation using high resolution/color Doppler ultrasound equipment.

RESULTS

Gestational age-specific reference ranges are given for the diameter of the pulmonary valve anulus, diameter of the ductus arteriosus at its beginning, middle, and end, ductal length, ductal diameter-to-pulmonary valve anulus diameter ratio, and the spatial relationship of the ductus arteriosus to the main pulmonary artery and to the aorta.

CONCLUSIONS

The presented data derived from a study group of 222 normal fetuses provide in-vivo insights into the morphology of the ductus arteriosus and its relationship to the adjacent vessels. The reference ranges may be helpful in prenatal diagnosis of cardiac malformations and abnormalities of the ductus arteriosus, such as obstruction or aneurysm from 13 to 41 weeks of gestation.

In utero development of hypertensive necrotizing pulmonary arterial lesions: report of a case associated with premature closure of the ductus arteriosus and pulmonary hypoplasia

Premature closure of the ductus arteriosus (PCDA) is an uncommon defect in which pulmonary hypertension (PH) has been documented by echocardiography in patients and by direct measurement after experimental PCDA in animals. The pulmonary vascular histology in human cases has received little attention but in the few recorded observations the vessels were either normal or showed increased muscularity. We report the case of a 31 week hydropic female stillborn monozygotic twin in whom postmortem examination disclosed PCDA and hypoplasia of the lungs. Atypical plexiform lesions with necrotizing pulmonary arteritis were present. These lesions represent vascular consequences of severe pulmonary hypertension produced by greatly enhanced blood flow through a restricted vascular bed resulting from the combined effects of these two abnormalities. The findings in this case of PCDA with presumed severe PH indicate that severe pulmonary vascular changes can develop in utero and that the interval of time needed for development of such chances in secondary PH is relatively short.

Fetal cerebral AV-malformation and cardiomegaly, diagnostic and therapeutic problems

Intracerebral aneurysms are rare. However they are potentially life-threatening. Today by means of ultrasound investigations these malformations can occasionally be identified prenatally. In these cases questions of intrauterine therapy, mode and time of delivery and postnatal treatment have to be discussed with the parents. We describe two cases with prenatal diagnosis of intracerebral arteriovenous malformations, diagnostic workup, therapeutic options and fetal outcome.

Circulatory changes following intrauterine closure of the ductus arteriosus in the human fetus and newborn

Prenatal detection of intrauterine closure of the ductus arteriosus unrelated to maternal administration of non-steroidal anti-inflammatory drugs or glucocorticoids made it possible to study the circulation in this condition in the human fetus and newborn by pre- and postnatal echocardiography and neonatal cardiac catheterization. At 38 weeks, the fetus presented intrauterine ductal closure associated with right ventricular dilatation and marked hypertrophy of the right ventricle and the interventricular septum, as well as severely diminished right ventricular fractional shortening and diminished pulmonary blood flow. Blood flow redistribution was characterized by reduced blood flow through the right heart and increased right-to-left shunting across the dilated foramen ovale. Pathological Doppler waveforms of the inferior vena cava and the ductus venosus were found, although the cardiotocogram was normal. Following unsuccessful induction of labour a Caesarean section was performed. Postnatal echocardiography confirmed the prenatal findings. Cardiac catheterization, performed because of persistent dependence on additional oxygen administration, revealed increased pulmonary vascular resistance, reduced pulmonary blood flow, and prolonged right-to-left shunt across the foramen ovale. Reduced peripheral pulmonary artery diameters were shown angiographically. Follow-up examinations revealed regression of right ventricular hypertrophy and recovery of right ventricular and pulmonary function. The findings confirm results from haemodynamic studies in animal experiments.

Clinical and echocardiographic evaluation of neonates with heart murmurs

In this study, 116 neonates (58M, 58F), aged 12h to 14d, with heart murmurs were examined by echocardiography: 26 were preterm and 90 full-term neonates. The clinical diagnosis was classified into definite heart disease, possible heart disease and innocent murmur. The final diagnosis was based on echocardiography and, in some cases, cardiac catheterization or surgery. The results showed that 97 (84%) neonates had heart diseases; 19 (16%) had a normal heart, including 7 with tricuspid regurgitation and 9 with physiological peripheral pulmonic stenosis. Out of 88 neonates with clinically definite heart disease, the final diagnosis was changed to normal heart in 9 (10%) cases and the lesion-specific diagnosis was changed in 9 (10%) neonates. In four cases, the clinical diagnosis of ventricular septal defect or pulmonary stenosis was changed to double-outlet right ventricle, single ventricle, hypoplastic left heart syndrome or tetralogy of Fallot. The clinical diagnosis was correct in 77-85% for varying simple lesions. In 5 of 21 neonates with clinically possible heart disease, the diagnosis was changed to normal heart. In one of six neonates with clinically innocent murmurs, the diagnosis was changed to small muscular ventricular septal defect. We concluded that 84% of heart murmurs in neonates were due to heart diseases and only 16% were innocent murmurs. Although clinical evaluation could determine the presence or absence of heart disease in most neonates, the lesion-specific diagnosis was not quite satisfactory. Echocardiography is necessary for neonates with a clinically diagnosed heart disease or possible heart diseases, and may be unnecessary for those with innocent murmurs diagnosed by paediatricians.

Doppler echocardiographic diagnosis of intrauterine closure of the ductus arteriosus

A case of in utero closure of the ductus arteriosus was detected by Doppler echocardiography at 31 weeks of gestation. It presented as a non-hydropic distressed fetus with ultrasound detection of tricuspid regurgitation. Pulsed Doppler ultrasound showed markedly decreased blood flow through the tricuspid and pulmonary valves and absent blood flow at the ductus arteriosus. These, as well as the resultant increased right-to-left shunting across the foramen ovale, were reaffirmed by colour flow mapping.

Transient neonatal tricuspid regurgitation: a Doppler echocardiographic study of three cases

Three patients with normal hearts and no pulmonary abnormality had neonatal tricuspid regurgitation causing cardiorespiratory distress and cyanosis. The signs of tricuspid regurgitation resolved over a few weeks. In the acute phase echocardiography showed gross dilatation of the right atrium and ventricle. The interatrial septum bulged into the left atrium during the whole cardiac cycle. Doppler echocardiography showed clinically significant tricuspid regurgitation, a right to left shunt through the foramen ovale, reduced flow through the pulmonary valve, and in two patients ductal flow into the pulmonary artery. In one patient tricuspid regurgitation was so great that it impeded the opening of the pulmonary valve and produced functional "atresia" of the pulmonary valve. The presence of regurgitant blood flow through the pulmonary valve showed that the "atresia" was functional rather than organic. Doppler echocardiographic study is useful in distinguishing functional neonatal tricuspid regurgitation from structural abnormality of the tricuspid valve.