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Fraga MV, Hedrick HL, Rintoul NE, Wang Y, Ash D, Flohr SJ, Mathew L, Reynolds T, Engelman JL, Avitabile CM. Congenital Diaphragmatic Hernia Patients with Left Heart Hypoplasia and Left Ventricular Dysfunction Have Highest Odds of Mortality. J Pediatr 2024:114061. [PMID: 38636784 DOI: 10.1016/j.jpeds.2024.114061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/18/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVES To describe the scope of left ventricular (LV) dysfunction and left heart hypoplasia (LHH) in infants with congenital diaphragmatic hernia (CDH), to determine associations with CDH severity, and to evaluate the odds of extracorporeal membrane oxygenation (ECMO) and death with categories of left heart disease. STUDY DESIGN Demographic and clinical variables were collected from a single-center, retrospective cohort of CDH patients from January 2017 through May 2022. Quantitative measures of LV function and LHH were prospectively performed on initial echocardiograms. LHH was defined as ≥2 of the following: Z-score ≤ -2 of any left heart structure or LV end-diastolic volume <3 mL. LV dysfunction was defined as shortening fraction <28%, ejection fraction <60%, or global longitudinal strain <20%. The exposure was operationalized as a four-group categorical variable (LV dysfunction +/-, LHH +/-). Logistic regression models evaluated associations with ECMO and death, adjusting for CDH severity. RESULTS One-hundred and eight-two patients (80.8% left CDH, 63.2% liver herniation, 23.6% ECMO, 12.1% mortality) were included. Twenty percent demonstrated normal LV function and no LHH (LV dysfunction-/LHH-), 37% normal LV function with LHH (LV dysfunction-/LHH+), 14% LV dysfunction without LHH (LV dysfunction+/LHH-), and 28% both LV dysfunction and LHH (LV dysfunction+/LHH+). There was a dose-response effect between increasing severity of left heart disease, ECMO use, and mortality. LV dysfunction+/LHH+ infants had the highest odds of ECMO use and death, after adjustment for CDH severity [OR (95% CI); 1.76 (1.20,2.62) for ECMO, 2.76 (1.63, 5.17) for death]. CONCLUSIONS In our large single-center cohort, CDH patients with LV dysfunction+/LHH+ had the highest risk of ECMO use and death.
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Affiliation(s)
- María V Fraga
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA.
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA
| | - Yan Wang
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Devon Ash
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
| | - Sabrina J Flohr
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tom Reynolds
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jenny L Engelman
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Catherine M Avitabile
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania. Philadelphia, PA; Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania, Philadelphia, PA
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Dragomir C, Manea AM, Enatescu VR, Lacatusu AAM, Lacatusu A, Henry OI, Boia M, Ilie C. Left heart hypoplasia operated using double pulmonary arterial banding with double arterial duct stenting: A case report. Exp Ther Med 2020; 20:193. [PMID: 33101483 DOI: 10.3892/etm.2020.9323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/10/2020] [Indexed: 01/21/2023] Open
Abstract
Hypoplastic left heart syndrome is a heterogeneous group of congenital cardiac malformations which associates hypoplastic/aplastic left ventricle, mitral and aortic valve, hypoplastic/atresia and severe aortic artery coarctation, and represents a medical-surgical emergency. We present a case of a newborn hospitalised in three clinics (two clinics from Timisoara and one from Vienna), and operated for hypoplastic left heart syndrome, without aortic coarctation, using a mixed technique cardiovascular repair surgery. The initial therapeutic conduct included maintaining the permeability of the arterial canal with prostaglandin E1. At the Vienna General Hospital, at the age of 17 days, bilateral banding of the pulmonary artery was performed and, at the age of 20 days, during the cardiac catheterisation, the Rashkind procedure (balloon atrial septostomy) was performed, with two stents being implanted in the arterial canal. Postoperative complications were postcardiotomy syndrome, pneumonia with Enterococcus faecalis and Stenotrophomonas maltophilia, sepsis with methicillin-resistant Staphylococcus aureus, coagulopathy, mixed anaemia, and metabolic acidosis. The patient died 1 month after the intervention due to cardiorespiratory arrest, bilateral congestive heart failure, left heart hypoplasia with shunt through the arterial canal and pulmonary artery banding, multiorgan failure, and severe secondary haemorrhagic disease. In conclusion, the initial cardiac surgical reconstruction consisted of a mixed technique, and anticoagulant medical treatment with heparin, antibiotics (bacterial endocarditis prophylaxis to be performed throughout life); postintervention hypoxic and infectious complications resulted in multiorgan failure and death.
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Affiliation(s)
- Cristina Dragomir
- Obstetrics-Gynaecology (XII) Department, Discipline of Neonatology and Childcare, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Aniko-Maria Manea
- Obstetrics-Gynaecology (XII) Department, Discipline of Neonatology and Childcare, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania.,Neonatology-Prematures Department, 'Louis Ţurcanu' Emergency Clinical Hospital for Children, 300011 Timisoara, Romania
| | - Virgil Radu Enatescu
- Neuroscience (VIII) Department, Discipline of Psychiatry, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | | | - Adrian Lacatusu
- 'Bega' Pediatric II Clinic, 'Pius Brinzeu' County Emergency Clinical Hospital, 300226 Timisoara, Romania.,Pediatrics (XI) Department, Pediatrics II Discipline, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Osakwe Ifeanyi Henry
- Pediatric Surgery and Orthopedics Department, Arad County Emergency Clinical Hospital, 310158 Arad, Romania
| | - Marioara Boia
- Obstetrics-Gynaecology (XII) Department, Discipline of Neonatology and Childcare, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania.,Neonatology-Prematures Department, 'Louis Ţurcanu' Emergency Clinical Hospital for Children, 300011 Timisoara, Romania
| | - Constantin Ilie
- Obstetrics-Gynaecology (XII) Department, Discipline of Neonatology and Childcare, 'Victor Babes' University of Medicine and Pharmacy, 300041 Timisoara, Romania.,Neonatology Department, 'Pius Brinzeu' County Emergency Clinical Hospital, 300226 Timisoara, Romania
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3
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Cohen J, Levasseur S, Simpson L, Miller R, Freud L. Fetal cardiac findings and hemodynamic changes associated with severe lower urinary tract obstruction in utero. Ultrasound Obstet Gynecol 2019; 54:780-785. [PMID: 30908816 DOI: 10.1002/uog.20271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/12/2019] [Accepted: 03/19/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To describe fetal echocardiographic findings associated with lower urinary tract obstruction (LUTO) and to compare anatomic and hemodynamic measurements between fetuses with LUTO and gestational age (GA)-matched controls, with an emphasis on quantitative indices of diastolic function and cardiac output. METHODS This was a retrospective cohort study of fetuses diagnosed with severe LUTO with giant bladder, which underwent at least one fetal echocardiogram at our center between January 2005 and June 2018. Fetuses with major congenital heart disease were excluded. Control fetuses did not have any structural or functional abnormalities and were GA-matched to the LUTO fetuses based on the time of the first fetal echocardiogram. Cardiac anatomy and hemodynamic measurements were compared between fetuses with LUTO and controls. In infants with LUTO, serial fetal and postnatal echocardiographic data were assessed, when available, and clinical outcomes were reviewed. RESULTS Twenty-six fetuses with LUTO and at least one fetal echocardiogram available were identified, one of which was excluded due to hypoplastic left heart syndrome, leaving 25 LUTO fetuses in the final cohort. The mean GA at the first fetal echocardiogram was 25.4 ± 5.1 weeks in the LUTO group and 25.3 ± 5.0 weeks in the control group. Common findings in fetuses with LUTO included cardiomegaly (40%), pericardial effusion (44%), right ventricular (RV) hypertrophy (64%) and left ventricular (LV) hypertrophy (48%). Compared with GA-matched controls, LUTO fetuses had lower ascending aorta Z-score (-0.10 ± 0.94 vs -0.93 ± 1.03; P = 0.02) and aortic isthmus Z-score (-0.14 ± 0.86 vs -1.62 ± 1.11; P < 0.001), shorter mitral valve inflow time indexed to cardiac cycle length (0.46 ± 0.04 vs 0.41 ± 0.06; P = 0.002), and worse (increased) LV myocardial performance index (0.39 ± 0.03 vs 0.44 ± 0.04; P < 0.001). In addition, the ratio of RV to LV cardiac index was higher in LUTO fetuses compared with controls (1.62 ± 0.13 vs 1.33 ± 0.11; P < 0.001). Of the 25 LUTO pregnancies, two were lost to follow-up, three underwent elective termination of pregnancy and three ended in intrauterine fetal demise. Four (16%) patients had mildly hypoplastic left-heart structures, comprising two with aortic arch hypoplasia and two with mitral and aortic stenosis. CONCLUSION In addition to presenting with cardiomegaly, pericardial effusion and ventricular hypertrophy, fetuses with LUTO demonstrate LV diastolic dysfunction and appear to redistribute cardiac output as compared to control fetuses, which may contribute to the development of left-heart hypoplasia. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Cohen
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - S Levasseur
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - L Simpson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - R Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - L Freud
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
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Lara DA, Morris SA, Maskatia SA, Challman M, Nguyen M, Feagin DK, Schoppe L, Zhang J, Bhatt A, Sexson-Tejtel SK, Lopez KN, Lawrence EJ, Andreas S, Wang Y, Belfort MA, Ruano R, Ayres NA, Altman CA, Aagaard KM, Becker J. Pilot study of chronic maternal hyperoxygenation and effect on aortic and mitral valve annular dimensions in fetuses with left heart hypoplasia. Ultrasound Obstet Gynecol 2016; 48:365-372. [PMID: 26700848 DOI: 10.1002/uog.15846] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 12/14/2015] [Accepted: 12/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE Acute maternal hyperoxygenation (AMH) results in increased fetal left heart blood flow. Our aim was to perform a pilot study to determine the safety, feasibility and direction and magnitude of effect of chronic maternal hyperoxygenation (CMH) on mitral and aortic valve annular dimensions in fetuses with left heart hypoplasia (LHH) after CMH. METHODS Gravidae with fetal LHH were eligible for inclusion in a prospective evaluation of CMH. LHH was defined as: sum of aortic and mitral valve annuli Z-scores < -4.5, arch flow reversal and left-to-right or bidirectional atrial level shunting without hypoplastic left heart syndrome or severe aortic stenosis. Gravidae with an affected fetus and with ≥ 10% increase in aortic/combined cardiac output flow after 10 min of AMH at 8 L/min 100% fraction of inspired oxygen were offered enrollment. Nine gravidae were enrolled from February 2014 to January 2015. The goal therapy was ≥ 8 h daily CMH from enrollment until delivery. Gravidae who were cared for from July 2012 to October 2014 with fetal LHH and no CMH were identified as historical controls (n = 9). Rates of growth in aortic and mitral annuli over the final trimester were compared between groups using longitudinal regression. RESULTS There were no significant maternal or fetal complications in the CMH cohort. Mean gestational age at study initiation was 29.6 ± 3.2 weeks for the intervention group and 28.4 ± 1.8 weeks for controls (P = 0.35). Mean relative increase in aortic/combined cardiac output after AMH was 35.3% (range, 18.1-47.9%). Median number of hours per day on CMH therapy was 9.3 (range, 6.5-14.6) and median duration of CMH was 48 (range, 33-84) days. Mean mitral annular growth was 0.19 ± 0.05 mm/week compared with 0.14 ± 0.05 mm/week in CMH vs controls (mean difference 0.05 ± 0.05 mm/week, P = 0.33). Mean aortic annular growth was 0.14 ± 0.03 mm/week compared with 0.13 ± 0.03 mm/week in CMH vs controls (mean difference 0.01 ± 0.03 mm/week, P = 0.75). More than 9 h CMH daily (n = 6) was associated with better growth of the aortic annulus in intervention fetuses (0.16 ± 0.03 vs 0.08 ± 0.02 mm/week, P = 0.014). CONCLUSIONS CMH is both safe and feasible for continued research. In this pilot study, the effect estimates of annular growth, using the studied method of delivery and dose of oxygen, were small. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D A Lara
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S A Morris
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S A Maskatia
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - M Challman
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - M Nguyen
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - D K Feagin
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - L Schoppe
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - J Zhang
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX, USA
| | - A Bhatt
- Department of Ophthalmology, Baylor College of Medicine, Houston, TX, USA
| | - S K Sexson-Tejtel
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - K N Lopez
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - E J Lawrence
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - S Andreas
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Y Wang
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - M A Belfort
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - R Ruano
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - N A Ayres
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - C A Altman
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - K M Aagaard
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - J Becker
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Byrne FA, Keller RL, Meadows J, Miniati D, Brook MM, Silverman NH, Moon-Grady AJ. Severe left diaphragmatic hernia limits size of fetal left heart more than does right diaphragmatic hernia. Ultrasound Obstet Gynecol 2015; 46:688-694. [PMID: 25597867 DOI: 10.1002/uog.14790] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 12/05/2014] [Accepted: 01/12/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To assess whether severity of congenital diaphragmatic hernia (CDH) correlates with the degree of left heart hypoplasia and left ventricle (LV) output, and to determine if factors leading to abnormal fetal hemodynamics, such as compression and reduced LV preload, contribute to left heart hypoplasia. METHODS This was a retrospective cross-sectional study of fetuses at 16-37 weeks' gestation that were diagnosed with CDH between 2000 and 2010. Lung-to-head ratio (LHR), liver position and side of the hernia were determined from stored ultrasound images. CDH severity was dichotomized based on LHR and liver position. The dimensions of mitral (MV) and aortic (AV) valves and LV were measured, and right and left ventricular outputs were recorded. RESULTS In total, 188 fetuses with CDH were included in the study, 171 with left CDH and 17 with right CDH. Fetuses with severe left CDH had a smaller MV (Z = -2.24 ± 1.3 vs -1.33 ± 1.08), AV (Z = -1.39 ± 1.21 vs -0.51 ± 1.05) and LV volume (Z = -4.23 ± -2.71 vs -2.08 ± 3.15) and had lower LV output (26 ± 10% vs 32 ± 10%) than those with mild CDH. MV and AV in fetuses with right CDH (MV, Z = -0.83 ± 1.19 and AV, Z = -0.71 ± 1.07) were larger than those in fetuses with left CDH, but LV outputs were similarly diminished, regardless of hernia side. Severe dextroposition and abnormal liver position were associated independently with smaller left heart, while LHR was not. CONCLUSION The severity of left heart hypoplasia correlates with the severity of CDH. Altered fetal hemodynamics, leading to decreased LV output, occurs in both right- and left-sided CDH, but the additional compressive effect on the left heart is seen only when the hernia is left-sided. Improved knowledge of the physiology of this disease may lead to advances in therapy and better risk assessment for use in counseling affected families.
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Affiliation(s)
- F A Byrne
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - R L Keller
- Department of Pediatrics, Division of Neonatology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - J Meadows
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - D Miniati
- Department of Surgery, Division of Pediatric Surgery, University of California, San Francisco, CA, USA
- Fetal Treatment Center, University of California, San Francisco, CA, USA
| | - M M Brook
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - N H Silverman
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
| | - A J Moon-Grady
- Department of Pediatrics, Divisions of Cardiology, University of California, Benioff Children's Hospital, San Francisco, CA, USA
- Fetal Treatment Center, University of California, San Francisco, CA, USA
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Kohl T. Chronic intermittent materno-fetal hyperoxygenation in late gestation may improve on hypoplastic cardiovascular structures associated with cardiac malformations in human fetuses. Pediatr Cardiol 2010; 31:250-63. [PMID: 20024652 PMCID: PMC2817075 DOI: 10.1007/s00246-009-9600-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 11/04/2009] [Indexed: 11/10/2022]
Abstract
Hypoplasia of cardiovascular structures is a common finding in fetuses with cardiac malformations. Materno-fetal hyperoxygenation (HO) during late gestation promotes venous return to the fetal heart. This analysis in human fetuses sought to define whether this "loading" effect might improve hypoplastic cardiovascular dimensions. Fifteen late-gestation fetuses presented with varying degrees of hypoplastic cardiovascular structures. In these cases, chronic intermittent materno-fetal HO was administered during periods ranging from 8 to 33 days. Cardiac measurements were taken before and at the end of treatment and translated into Z-scores as well as plotted on normal growth charts. During the treatment period, chronic intermittent materno-fetal HO was associated with improved dimensions of >or=1 hypoplastic cardiovascular structures in most fetuses. However, in some cases, the effect of HO was neutralized or impaired by the presence of ventricular septal defects as well as obstructions to ventricular filling or emptying. Chronic intermittent materno-fetal HO near term may be associated with improvements of hypoplastic cardiovascular dimensions in fetuses with a spectrum of cardiac malformations. This effect may facilitate postnatal treatment and improve prognosis in suitable cases.
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Affiliation(s)
- Thomas Kohl
- German Center for Fetal Surgery and Minimally Invasive Therapy, University Hospital of Bonn, Bonn 53105, Germany.
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