Fetal Pulmonary Venous Flow and Restrictive Foramen Ovale in Hypoplastic Left Heart

Abstract

Purpose: Hypoplastic left heart (HLH) with intact or restrictive interatrial communication (HLH-IAS/RAS) is associated with high mortality rates. The object was to correlate pulmonary venous (PV) Doppler spectra and direct foramen ovale (FO) assessment with the neonatal need for early atrial septostomy (EAS) and neonatal outcome.

Materials and Methods: We reviewed all prenatal echocardiograms and outcomes of 51 fetuses with HLH and information about the interatrial communication between 1994 – 2011. IAS/RAS was defined as a small/absent interatrial shunt on 2-dimensional imaging. Three PV Doppler spectra were observed: type A: continuous forward flow with a small a wave reversal; type B: continuous forward flow with increased a-wave reversal; type C: brief to-and-fro flow.

Results: Three of 51 neonates with type C pulmonary venous flow pattern and suspicion of IAS/RAS on 2-dimensional (2-DE) evaluation required EAS. In one fetus pulmonary venous flow changed from type B to type C spectra throughout gestation. Fetuses with type C spectra showed a 71.4 % survival after 30 days compared to 92.3 % in fetuses with type A spectra. Short term survival after EAS was 33 %.

Conclusion: Prenatal PV flow pattern and 2-DE of the FO size help in identifying the fetus at risk for neonatal EAS and patient selection for fetal cardiac intervention. Most late second trimester values will not change over time.

Zusammenfassung

Ziel: Das hypoplastische Linksherz (HLH) mit intakter oder restriktiver interatrialer Kommunikation (HLH-IAS/RAS) ist mit einer hohen Mortalitätsrate assoziiert. Mit dieser Arbeit sollte die Bestimmung von Pulmonalvenen(PV)-Doppler-Spektren, die direkte Messung des Foramen ovale, die Notwendigkeit einer frühen atrialen Septostomie (EAS) und das neonatale Outcome auf eine Korrelation hin untersucht werden.

Material und Methoden: Wir untersuchten alle pränatalen Echokardiogramme und Outcomes von 51 Feten mit der Diagnose eines HLH und der Information über die interatriale Kommunikation zwischen 1994 und 2011. IAS/RAS wurde als schmaler/nicht darstellbarer Shunt im 2-dimensionalen B-Bild definiert. 3 verschiedene PV-Doppler-Spektren konnten nachgewiesen werden: Typ A: kontinuierlicher Vorwärtsfluss mit einem geringen Rückwärtsfluss während der a-Welle; Typ B: kontinuierlicher Vorwärtsfluss mit gesteigertem Rückwärtsfluss während der a-Welle; Typ C: Pendelfluss.

Ergebnisse: Bei 3 der 51 Neugeborenen mit einem PV Spektrum vom Typ C und dem Verdacht auf IAS/RAS in der 2-dimensionalen Auswertung (2-DE) war eine EAS notwendig. In einem Fall kam es im Laufe der Schwangerschaft zu einem Wechsel von Typ B zu Typ C. Feten mit Typ-C-Spektrum wiesen nach 30 Tagen eine Überlebensrate von 71,4 % auf, bei Feten mit Typ-A-Spektrum lag diese dagegen bei 92,3 %. Das Kurzzeit-Überleben nach EAS betrug 33 %.

Schlussfolgerung: Mithilfe der pränatalen Bestimmung der PV-Flussmuster und der 2-DE der FO-Größe können Feten mit einem Risiko für eine neonatale EAS und Patienten für eine fetale kardiale Intervention selektiert werden. Im späten zweiten Trimester erhobene Messwerte ändern sich im weiteren Verlauf der Schwangerschaft meist nicht mehr.

Key words

hypoplastic left heart - foramen ovale - interatrial communication - early atrial septostomy

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