James J. Paul

Fetal congestive heart failure: correlation of Tei-index and Cardiovascular-score.

Abstract Introduction: Congestive heart failure (CHF) may be present in fetuses with hydrops fetalis (HF) and the severity is difficult to quantitate. Differential ventricular dysfunction may be present in the fetus with CHF. A non-geometric measure of ventricular function that is not afterload dependent would be useful to measure the severity of myocardial dysfunction. Methods: Tei-index (isovolumetric time/ejection time) was measured prenatally in 23 normals (24–34 weeks gestational age-GA) and in 7 with HF (24–34 weeks GA). Prenatal CHF severity was graded by a 10 point cardiovascular (CV) score (2 points each for absence of hydrops, normal venous Doppler, heart function, arterial Doppler, and heart size, and 10/10 = normal). A paired student t-test was used to compare RV and LV and nonpaired t-test compared HF and normals. Tei-index and CV score were correlated. Results: Tei-index normals were 0.38 ± 0.04 in the right ventricle (RV) and 0.41 ± 0.05 in the left ventricle (LV) and there were no significant RV-LV or gestational age (GA) differences. Among HF fetuses, RV and LV Tei-indices were both significantly increased (0.54 and 0.92) and not significantly different. CV score ranged from 2 to 8 (mean 5.43 out of 10) and correlated inversely with Tei-index (r = −0.52, r = −0.68). Conclusion: Hydrops fetalis is associated with biventricular dysfunction and congestive heart failure. Tei-index correlates with CV score obtained within two weeks of delivery or intrauterine death. Tei-index may be useful in the serial assessment of myocardial dysfunction in the fetus with hydrops.

Cardiac malposition, redistribution of fetal cardiac output, and left heart hypoplasia reduce survival in neonates with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation☆☆☆★

OBJECTIVE To evaluate cardiac position, left ventricular (LV) mass, and distribution of fetal cardiac output in infants with congenital diaphragmatic hernia (CDH) who required extracorporeal membrane oxygenation (ECMO), and in control subjects. STUDY DESIGN Echocardiograms were performed on 23 neonates with CDH shortly after birth, and repeated within 5 days of repair on ECMO in 21 infants,aand on 12 infants receiving ECMO for other diagnoses, and on 10 healthy, term neonates. Cardiac angle between the midline saggital plane and the interventriculak septum was measured, and deviation from normal (45 degrees) was determined. The ratio of cross-sectional areas (proportional to flows) across the pulmonary (PV) and aortic (AV) valves was determined (PV2/AV2) in 19 infants with CDH and in the healthy control subjects. RESULTS Thirteen (57%) infants with CDH survived and 10 (43%) died, with no difference in cardiac deviation before surgical repair (35 +/- 13 degrees vs Cardiac deviation persisted after repair in nonsurvivors (27 +/- 14 degrees vs 800.01 and LV mass was significantly less (1.68 +/- 0.39 vs 3.05 +/- 1.20 gm/kg, p00.0005). Neonates requiring ECMO for other diagnoses and well term babies did not have cardiac angle deviations; both these groups had a greater LV mass than did the infants with CDH. The PV2/AV2 flow ratios were higher in infants with CDH (median, 1.73; range, 1.25 to 16.50) compared with those of the healthy infants (0.96, 0.79 to 1.69, p < 0.0002). CONCLUSIONS Cardiac malposition persisted despite CDH repair in nonsurvivors with low LV mass, and fetal cardiac output was redistributed away from the left ventricle. Lung hypoplasia with reduced pulmonary flow returning to the left atrium and altered left atrial hemodynamics may result in LV hypoplasia

ST-segment depression during adenosine infusion as a predictor of myocardial ischemia

The incidence and hemodynamic changes associated with ST-segment depression during adenosine stress testing are poorly defined. To examine this, 550 consecutive patients who underwent adenosine perfusion testing were evaluated for the development of ST-segment depression. At least 1 mm of horizontal or downsloping depression developed in 82 patients (15.9%) and was observed with similar frequency in patients with normal scans and those with only fixed defects. ST depression developed in 58 of 242 patients with reversible defects (sensitivity = 24%) and in only 24 of 275 patients without reversible defects (specificity = 91%). Its presence was highly predictive of reversible perfusion defects (predictive accuracy = 71%). Similar findings were observed in patients with and without ECG evidence of left ventricular hypertrophy. Patients with ST depression had perfusion defects in more vessel distributions, had more severe defects, and had a greater increase in heart rate during adenosine infusion. Thus ST-segment depression occurs infrequently during adenosine infusion but is specific for and predictive of myocardial ischemia, as evidenced by reversible perfusion scan defects. Patients with ST depression have more severe disease and develop faster heart rates during infusion, which could result in decreased coronary perfusion during diastole allowing for the development of myocardial ischemia.

Doppler in fetal heart failure.

Fetal echocardiography has progressed to be able to diagnose many forms of congenital heart disease (CHD) and to assess the prognosis of cardiac lesions based on their anatomy and presentation in utero. Fetal echocardiography is for pregnancies at risk of structural, functional, and rhythm-related fetal heart disease. Routine obstetrical ultrasound screening is critical in the prenatal detection of fetal heart disease/CHD. With or without CHD, fetal heart dysfunction defined as inadequate tissue perfusion may occur. Perinatal problems other than CHD can also be assessed, such as the effects of noncardiac malformations that affect hemodynamics, that is, twin-twin transfusion. Cardiac rhythm can affect cardiac function and outcome, and prenatal diagnosis can be lifesaving. A tool for the assessment of cardiac function is the Cardiovascular Profile Score that combines ultrasonic markers of fetal cardiovascular unwellness based on univariate parameters, which have been correlated with perinatal mortality. This “heart failure score” could potentially be used in much the same way as and in combination with the biophysical profile score. This study will present a summary of fetal Doppler and its place in the diagnosis and assessment of prognosis of fetal heart failure.

Survival in Infarct Related Intramyocardial Dissection: Importance of Early Echocardiography and Prompt Surgery

Infarct related intramyocardial dissection, an unusual mechanical complication associated with recent inferior/inferoposterior myocardial infarction, is characterized by a septal defect and a dissection tract that originates on the left side of the interventricular septum, extends beyond the septum into the right ventricular free wall, and subsequently re‐enters the right ventricle. The utility of echo‐cardiography for diagnosis has been described. Despite aggressive therapy, the prognosis of intramyocardial dissection is reported to be dismal. We describe the use of prompt echocardiography in two patients, which established the diagnosis of infarct related intramyocardial dissection allowing early definitive surgery and long‐term survival.

Infarct Related Intramyocardial Dissection

Dissecting intramyocardial hematoma is a rare mechanical complication of acute myocardial infarction (MI). We describe four patients who sustained an acute inferior / inferoposterior MI, developed a new pansystolic murmur, and hemodynamically deteriorated in the first week following infarction. Two‐dimensional echocardiography identified a complex rupture that dissected across the inferior portion of the interventricular septum, tunneled through right ventricular (RV) myocardium, and reentered the cavity of the RV. Color flow Doppler was particularly valuable in identifying the serpiginous course of the dissections as well as the entry and exit points. Cardiac catheterization demonstrated markedly increased right heart filling pressures, multivessel coronary artery disease, and evidence of the ventricular septal rupture. One patient died prior to surgery, and the other three expired within 24 hours of attempted surgical repair. We conclude that intramyocardial dissection is a complication of inferior / inferoposterior MI that can be rapidly diagnosed by echocardiography.

Automatic Border Detection for Assessment of Left Ventricular Diastolic Function Among Normal Neonates: Comparison with Doppler Echocardiography.

Doppler echocardiography is the standard noninvasive method to assess left ventricular (LV) diastolic function. Recently, automatic border detection (ABD), a method based on analysis of integrated ultrasonic backscatter, has been introduced permitting real‐time, on‐line assessment of LV diastolic function. A comparison of these methods in normal, full‐term neonates has not been performed. Therefore, the objectives of this study were to evaluate the usefulness of ABD in the assessment of LV diastolic function among normal neonates, to compare parameters obtained with the ABD method with standard Doppler‐derived indexes of diastolic function, and to assess the reproducibility of ABD measurements. We studied 17 consecutive normal neonates during natural sleep with both methods shortly after birth (mean 17.4 ± 3.9 h) and approximately 2 weeks later (mean 14.8 ± 2.2 days). An average of five consecutive cardiac cycles were performed. Similar to Doppler indexes, no significant change in any ABD parameter of diastolic function occurred between the early and later studies. A complete ABD study could be performed within 5 minutes. Mean interobserver variation for individual ABD measurements ranged from 0% to 11%. Compared with Doppler, rapid filling fraction was greater and atrial filling fraction was less with ABD. Regression analysis showed poor correlation of these parameters between methods, but their ratio by each method remained constant between studies. A similar poor correlation existed between peak E wave velocity by Doppler and peak rapid filling rate by ABD and between peak A wave velocity by Doppler and peak atrial filling rate by ABD. These differences may be explained by technical factors and different aspects of diastolic filling assessed by each method. This study indicated that ABD was a feasible and reproducible method compared with Doppler echocardiography for serial evaluation of LV diastolic function among neonates.

REDISTRIBUTION OF FETAL CARDIAC OUTPUT IN CONGENITAL DIAPHRAGMATIC HERNIA(CDH): † 1001

Introduction: Cross-sectional area of arterial vessels is proportional to the flow through them. To assess the relative distributions of cardiac output (CO) between the left and right ventricles in fetuses with CDH, neonates with diaphragmatic defects were evaluated for quantitative morphometric analysis of the size of the great arteries.

CARDIAC MALPOSITION IN NEONATES WITH CONGENITAL DIAPHRAGMATIC HERNIA (CDH) TREATED WITH EXTRA-CORPOREAL MEMBRANE OXYGENATION (ECMO): † 1408

CARDIAC MALPOSITION IN NEONATES WITH CONGENITAL DIAPHRAGMATIC HERNIA (CDH) TREATED WITH EXTRA-CORPOREAL MEMBRANE OXYGENATION (ECMO): † 1408

Automatic Border Dectection in the Evaluation of Diastolic Function in Normal Neonates 129

Automatic border detection (ABD) is an alternative method to Doppler echocardiography (DE) for assessment of LV diastolic function. To date, no information is available regarding the utility of ABD to assess diastolic function among normal neonates. Methods: To compare ABD to standard DE parameters and to assess the reproducibility of ABD among observers, we studied 17 normal full-term neonates (mean birth wt 3.5±0.3 kg) at birth (17.4±3.9 hr) and again at 14.8±2.2 days of life to evaluate LV diastolic function by both methods. DE parameters obtained at the mitral leaflet tips were: Peak E-and A-wave velocity; E/A ratio; E, A, and total time velocity integrals (TVI); deceleration time. Rapid and atrial filling fractions were derived from the TVIs. Isovolumic relaxation time was measured. ABD parameters including rapid filling fraction (RFF) area change, atrial filling fraction (AFF) area change, ratio RFF/AFF, peak rapid and atrial filling rates and their ratio were obtained in the short-axis view after proper gain and region of interest were set. An average of 5 cardiac cycles was used for each measurement. Results: No significant change was observed in any ABD or DE parameter between birth and later studies. Interobserver variability for individual ABD measurements ranged from 0-11%. In comparison to DE, the RFF was greater and the AFF was less by ABD. Regression analysis showed only weak correlation between each measure by the 2 methods. However, the relationship between RFF and AFF obtained by each method was constant across the studies. Similarly, weak correlations were observed when peak E velocity by DE and peak rapid filling rate by ABD and peak A velocity by DE and peak atrial filling rate by ABD were compared.Conclusions: (1) Similar to traditional DE parameters, the ABD method showed that no significant change in LV diastolic function occurred in the first 2 weeks of life. (2) Weak correlation between ABD and DE parameters of filling was observed which may relate to technical differences between methods. (3) ABD was a reproducible and reliable method to assess LV diastolic function in neonates.