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Lee FT, Sun L, Szabo A, Milligan N, Saini A, Chetan D, Hunt JL, Macgowan CK, Freud L, Jaeggi E, Van Mieghem T, Kingdom J, Miller SP, Seed M. Safety and feasibility pilot study of continuous low-dose maternal supplemental oxygen in fetal single ventricle heart disease. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:493-503. [PMID: 38629477 DOI: 10.1002/uog.27657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/12/2024] [Accepted: 03/16/2024] [Indexed: 10/02/2024]
Abstract
OBJECTIVE Fetuses with single ventricle physiology (SVP) exhibit reductions in fetal cerebral oxygenation, with associated delays in fetal brain growth and neurodevelopmental outcomes. Maternal supplemental oxygen (MSO) has been proposed to improve fetal brain growth, but current evidence on dosing, candidacy and outcomes is limited. In this pilot study, we evaluated the safety and feasibility of continuous low-dose MSO in the setting of SVP. METHODS This single-center, open-label, pilot phase-1 safety and feasibility clinical trial included 25 pregnant individuals with a diagnosis of fetal SVP. Participants self-administered continuous MSO using medical-grade oxygen concentrators for up to 24 h per day from the second half of gestation until delivery. The primary aim was the evaluation of the safety profile and feasibility of MSO. A secondary preliminary analysis was performed to assess the impact of MSO on the fetal circulation using echocardiography and late-gestation cardiovascular magnetic resonance imaging. Early outcomes were assessed, including perinatal growth and preoperative brain injury, and neurodevelopmental outcomes were assessed at 18 months using the Bayley Scales of Infant and Toddler Development 3rd edition, and compared with those of a contemporary fetal SVP cohort (n = 217) that received the normal standard of care (SOC). RESULTS Among the 25 participants, the median maternal age at conception was 35 years, and fetal SVP diagnoses included 16 with right ventricle dominant, eight with left ventricle dominant and one with indeterminate ventricular morphology. Participants started the trial at approximately 29 + 2 weeks' gestation and self-administered MSO for a median of 16.1 h per day for 63 days, accumulating a median of 1029 h of oxygen intake from enrolment until delivery. The only treatment-associated adverse events were nasal complications that were resolved typically by attaching a humidifier unit to the oxygen concentrator. No premature closure of the ductus arteriosus or unexpected fetal demise was observed. In the secondary analysis, MSO was not associated with any changes in fetal growth, middle cerebral artery pulsatility index, cerebroplacental ratio or head-circumference-to-abdominal-circumference ratio Z-scores over gestation compared with SOC. Although MSO was associated with changes in umbilical artery pulsatility index Z-score over the study period compared with SOC (P = 0.02), this was probably due to initial baseline differences in placental resistance. At late-gestation cardiovascular magnetic resonance imaging, MSO was not associated with an increase in fetal cerebral oxygen delivery. Similarly, no differences were observed in neonatal outcomes, including preoperative brain weight Z-score and brain injury, mortality by 18 months of age and neurodevelopmental outcomes at 18 months of age. CONCLUSIONS This pilot phase-1 clinical trial indicates that low-dose MSO therapy is safe and well tolerated in pregnancies diagnosed with fetal SVP. However, our protocol was not associated with an increase in fetal cerebral oxygen delivery or improvements in early neurological or neurodevelopmental outcomes. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- F-T Lee
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - L Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - A Szabo
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - N Milligan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - A Saini
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - D Chetan
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | | | - C K Macgowan
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
- Department of Medical Biophysics, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - L Freud
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - E Jaeggi
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
| | - T Van Mieghem
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - J Kingdom
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - S P Miller
- Department of Pediatrics, BC Children's Hospital and University of British Columbia, Vancouver, Canada
- Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - M Seed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
- Translational Medicine Program, SickKids Research Institute, Toronto, Canada
- Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Alonzo M, Contreras J, Bering J, Zhao MT. In Vivo and In Vitro Approaches to Modeling Hypoplastic Left Heart Syndrome. Curr Cardiol Rep 2024:10.1007/s11886-024-02122-6. [PMID: 39340601 DOI: 10.1007/s11886-024-02122-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 08/20/2024] [Indexed: 09/30/2024]
Abstract
PURPOSE OF REVIEW Hypoplastic left heart syndrome (HLHS) is a critical congenital heart defect characterized by the underdevelopment of left-sided heart structures, leading to significant circulatory challenges, and necessitating multiple surgeries for survival. Despite advancements in surgical interventions, long-term outcomes often involve heart failure, highlighting the need for a deeper understanding of HLHS pathogenesis. Current in vivo and in vitro models aim to recapitulate HLHS anatomy and physiology, yet they face limitations in accuracy and complexity. RECENT FINDINGS In vivo models, including those in chick, lamb, and mouse, provide insights into hemodynamic and genetic factors influencing HLHS. In vitro models using human induced pluripotent stem cells offer valuable platforms for studying genetic mutations and cellular mechanisms. This review evaluates these models' utility and limitations, and proposes future directions for developing more sophisticated models to enhance our understanding and treatment of HLHS.
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Affiliation(s)
- Matthew Alonzo
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43215, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, 43215, USA
| | - Javier Contreras
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43215, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, 43215, USA
| | - Jakob Bering
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43215, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, 43215, USA
| | - Ming-Tao Zhao
- Center for Cardiovascular Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, 43215, USA.
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, 43215, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, 43210, USA.
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, 43210, USA.
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Onohara D, Hagen M, Louey S, Giraud G, Jonker S, Padala M. Chronic in utero mitral inflow obstruction unloads left ventricular volume in a novel late gestation fetal lamb model. JTCVS OPEN 2023; 16:698-707. [PMID: 38204723 PMCID: PMC10775114 DOI: 10.1016/j.xjon.2023.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 01/12/2024]
Abstract
Objective The in utero no flow/no grow hypothesis postulates that reduced inflow of blood into the left ventricle due to a stenotic mitral valve could lead to ventricular hypoplasia and hypoplastic left heart syndrome. This has been demonstrated in chick embryos, but less so in large animals. We investigated the impact of mitral obstruction on left and right ventricular growth in fetal lambs. Methods Twelve pregnant ewes, most bearing twins, were instrumented at 119 ± 1 days gestational age. Carotid artery and jugular vein catheters, an ascending aorta flow probe, and a left atrial deflated balloon catheter were implanted into 1 fetus (left atrial balloon group), and the twin remained an uninstrumented control. The balloon was inflated gradually over 8 days until net antegrade aortic flow was eliminated. Fetal transesophageal echocardiography was performed at the time of surgery and just before termination in both groups. Results Terminal fetal body weights were comparable between groups. Terminal heart/body weight ratio was higher in left atrial balloon group fetuses (6.9 ± 0.8 g/kg) compared with controls (5.9 ± 0.6 g, P = .0126). The left ventricular/right ventricular weight ratio was 24% (P = .0077) lower in left atrial balloon group fetuses than in controls. Left ventricular/heart weight (0.24 ± 0.04 g/g vs 0.30 ± 0.04 g/g, P = .0009), left ventricular end-diastolic volume (2.3 ± 0.7 mL vs 7.1 ± 0.8 mL; P = .0012), and left ventricular end-systolic volume (1.01 mL [0.95-1.95 mL] vs 3.38 mL [3.28-3.57 mL], P = .0042) were lower in left atrial balloon group fetuses compared with controls. Right ventricular weight (g/kg), right ventricular end-diastolic volume, and right ventricular end-systolic volume were similar between groups. Conclusions In this late-gestation fetal lamb model, in utero obstruction of mitral inflow slowed left ventricular growth and caused right ventricular remodeling.
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Affiliation(s)
- Daisuke Onohara
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, Ga
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Matthew Hagen
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Samantha Louey
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - George Giraud
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
- Department of Cardiology, Portland Veterans Affairs Medical Center, Portland, Ore
| | - Sonnet Jonker
- Center for Development Health, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Muralidhar Padala
- Structural Heart Research and Innovation Laboratory, Carlyle Fraser Heart Center at Emory University Hospital Midtown, Atlanta, Ga
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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