Advertisement

Prenatal Identification of Restrictive and Non-restrictive Ventricular Septal Defects Based on End-Systolic Flow Patterns in the Fetal Aortic Isthmus

  • Jean-Claude FouronEmail author
  • Julie Thomas-Chabaneix
  • Sophie Brisebois
  • Annie Berger
  • Nagib Dahdah
Original Article

Abstract

Fetuses with large ventricular septal defects (VSDs) must be closely monitored during the perinatal period. Intrauterine assessment of size of septal defects with bidimensional echocardiography are unreliable. The objective of the present study is to document the contribution of flow pattern analysis in the fetal aortic isthmus for prenatal identification of large non-restrictive VSDs requiring immediate postnatal attention. We conducted a cross-sectional retrospective study of Doppler recordings from patients referred to our Fetal Cardiology Unit and diagnosed with one or multiple VSDs from January 2006 to November 2015. Three groups were defined: (1) large non-restrictive VSDs (n = 11) with postnatal cardiac failure (2) small restrictive VSDs (n = 28) asymptomatic, and (3) absence of cardiac abnormality (n = 66). The Isthmic end-Systolic Index (ISI) was computed to quantify aortic isthmus flow and compared between the three groups. Fetuses with restrictive VSD and control group showed similar ISI: stable at 0.20 ± 0.01 up to 27 weeks of gestation and dropping later due to the fall of end-systolic velocities in the aortic isthmus. By 35 weeks, a brief end-systolic retrograde flow was present, associated with a further fall of ISI down to −0.26 ± 0.05. In contrast, ISI of fetuses with large non-restrictive VSDs were unchanged throughout gestation (0.18 ± 0.06), becoming significantly higher during the last weeks of gestation compared to the two other groups (p < 0.001). In fetuses with VSDs, the ISI measurement from the aortic isthmus Doppler flow during the second half of gestation is a reliable predictor of a large non-restrictive defect with risk of major postnatal clinical impact.

Keywords

Fetal heart defect Ventricular septal defect Aortic isthmus Isthmic Systolic Index (ISI) Prediction Risk stratification 

Notes

Acknowledgements

The authors are grateful to Stéphanie Bilodeau and Danielle Buch, medical writers, for critical revision and editing of the manuscript.

Funding

This investigation was supported (in part) by a research Grant (Grant # MOP-97986) from the Canadian Institutes of Health Research.

Compliance with Ethical Standards

Conflict of interest

Dr. Jean-Claude Fouron declares that he has no conflict of interest. Dr. Julie Chabaneix Thomas declares that she has no conflict of interest. Dr. Nagib Dahdah declares that he has no conflict of interest. Ms. Sophie Brisebois declares that she has no conflict of interest. Ms. Annie Berger declares that she has no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Fouron JC (2003) The unrecognized physiological and clinical significance of the fetal aortic isthmus. Ultrasound Obstet Gynecol 22:441–447CrossRefGoogle Scholar
  2. 2.
    Rychik J (2004) Fetal cardiovascular physiology. Pediatr Cardiol 25:201–209CrossRefGoogle Scholar
  3. 3.
    Tynan D, Alphonse J, Henry A, Welsh AW (2016) The aortic isthmus: a significant yet underexplored watershed of the fetal circulation. Fetal Diagn Ther 40:81–93CrossRefGoogle Scholar
  4. 4.
    Thanasuan S, Phithakwatchara N, Nawapan K (2014) Reference values for fetal aortic isthmus blood flow parameters at 24 to 38 weeks' gestation. Prenat Diagn 34:241–245CrossRefGoogle Scholar
  5. 5.
    Makikallio K, Jouppila P, Rasanen J (2003) Retrograde aortic isthmus net blood flow and human fetal cardiac function in placental insufficiency. Ultrasound Obstet Gynecol 22:351–357CrossRefGoogle Scholar
  6. 6.
    Hidar S, Zaafouri R, Bouguizane S, Chaieb A, Jerbi M, Bibi M, Khairi H (2004) Prognostic value of fetal aortic isthmus Doppler waveform in intrauterine growth retardation: prospective longitudinal study. J Gynecol Obstet Biol Reprod 33:745–752CrossRefGoogle Scholar
  7. 7.
    Fouron JC, Gosselin J, Raboisson MJ, Lamoureux J, Tison CA, Fouron C, Hudon L (2005) The relationship between an aortic isthmus blood flow velocity index and the postnatal neurodevelopmental status of fetuses with placental circulatory insufficiency. Am J Obstet Gynecol 192:497–503CrossRefGoogle Scholar
  8. 8.
    Rizzo G, Capponi A, Vendola M, Pietrolucci ME, Arduini D (2008) Relationship between aortic isthmus and ductus venosus velocity waveforms in severe growth restricted fetuses. Prenat Diagn 28:1042–1047CrossRefGoogle Scholar
  9. 9.
    Del Rio M, Martinez JM, Figueras F, Bennasar M, Olivella A, Palacio M, Coll O, Puerto B, Gratacos E (2008) Doppler assessment of the aortic isthmus and perinatal outcome in preterm fetuses with severe intrauterine growth restriction. Ultrasound Obstet Gynecol 31:41–47CrossRefGoogle Scholar
  10. 10.
    Hernandez-Andrade E, Crispi F, Benavides-Serralde JA, Plasencia W, Diesel HF, Eixarch E, Acosta-Rojas R, Figueras F, Nicolaides K, Gratacos E (2009) Contribution of the myocardial performance index and aortic isthmus blood flow index to predicting mortality in preterm growth-restricted fetuses. Ultrasound Obstet Gynecol 34:430–436CrossRefGoogle Scholar
  11. 11.
    Acharya G, Tronnes A, Rasanen J (2011) Aortic isthmus and cardiac monitoring of the growth-restricted fetus. Clin Perinatol 38:113–125CrossRefGoogle Scholar
  12. 12.
    Fouron JC, McNeal-Davidson A, Abadir S, Fournier A, Bigras JL, Boutin C, Brassard M, Raboisson MJ, van Doesburg N, Berger A, Brisebois S, Gendron R (2017) Prenatal diagnosis and prognosis of accelerated idioventricular rhythm. Ultrasound Obstet Gynecol 50:624–631CrossRefGoogle Scholar
  13. 13.
    Mari G, Deter RL (1992) Middle cerebral artery flow velocity waveforms in normal and small-for-gestational-age fetuses. Am J Obstet Gynecol 166:1262–1270CrossRefGoogle Scholar
  14. 14.
    Kenny JF, Plappert T, Doubilet P, Saltzman DH, Cartier M, Zollars L, Leatherman GF, St John Sutton MG (1986) Changes in intracardiac blood flow velocities and right and left ventricular stroke volumes with gestational age in the normal human fetus: a prospective Doppler echocardiographic study. Circulation 74:1208–1216CrossRefGoogle Scholar
  15. 15.
    Chabaneix J, Fouron JC, Sosa-Olavarria A, Gendron R, Dahdah N, Berger A, Brisebois S (2014) Profiling left and right ventricular proportional output during fetal life with a novel systolic index in the aortic isthmus. Ultrasound Obstet Gynecol 44:176–181CrossRefGoogle Scholar
  16. 16.
    Garcia-Canadilla P, Crispi F, Cruz-Lemini M, Valenzuela-Alcaraz B, Rudenick PA, Gratacos E, Bijnens BH (2017) Understanding the aortic isthmus doppler profile and its changes with gestational age using a lumped model of the fetal circulation. Fetal Diagn Ther 41:41–50CrossRefGoogle Scholar
  17. 17.
    Mosimann B, Zidere V, Simpson JM, Allan LD (2014) Outcome and requirement for surgical repair following prenatal diagnosis of ventricular septal defect. Ultrasound Obstet Gynecol 44:76–81CrossRefGoogle Scholar
  18. 18.
    Lethor JP, Marcon F, de Moor M, King ME (2000) Physiology of ventricular septal defect shunt flow in the fetus examined by color Doppler M-mode. Circulation 101:E93CrossRefGoogle Scholar
  19. 19.
    De Muylder X, Fouron JC, Bard H, Riopel L, Urfer F (1984) The difference between the systolic time intervals of the left and right ventricles during fetal life. Am J Obstet Gynecol 149:737–740CrossRefGoogle Scholar
  20. 20.
    Cook CD, Drinker PA, Jacobson HN, Levison H, Strang LB (1963) Control of pulmonary blood flow in the foetal and newly born lamb. J Physiol 169:10–29CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Jean-Claude Fouron
    • 1
    • 4
    Email author
  • Julie Thomas-Chabaneix
    • 1
    • 2
  • Sophie Brisebois
    • 1
  • Annie Berger
    • 1
  • Nagib Dahdah
    • 3
  1. 1.Fetal Cardiology Unit, Pediatric Cardiology DivisionCHU Sainte Justine, University of MontrealMontrealCanada
  2. 2.Cardiac Catheterization Laboratory, Pediatric Cardiology DivisionCHU Sainte Justine, University of MontrealMontrealCanada
  3. 3.Pediatric and Congenital Cardiology Unit, Bordeaux University HospitalPessacFrance
  4. 4.Fetal Cardiology Unit, Pediatric Cardiology DivisionCHU Sainte-JustineMontrealCanada

Personalised recommendations