John Bokowski

Prominent coronary artery flow with normal coronary artery anatomy is a rare but ominous harbinger of poor outcome in the fetus.

Abstract Objectives: “Heart sparing” refers to prominent antegrade fetal coronary artery (CA) blood flow readily visualized by color Doppler and is a harbinger of poor outcome in growth restricted fetus, but little is known of the features and presentation of heart sparing in normally grown fetuses. Our objective was to describe heart sparing effects in normally grown fetuses, and compare the presentation and outcome of heart sparing between fetuses with growth restriction and those who were normally grown. Methods: In a series of fetuses with prominent antegrade CA flow, we assessed Doppler flow profiles in the aortic isthmus, ductus venosus (DV), umbilical vein (UV), umbilical artery (UA) and middle cerebral artery (MCA). We calculated MCA and UA systolic/diastolic ratios and the cerebral placental ratio, and measured fetal biometry. We evaluated cardiac function using the myocardial performance index (MPI) and the cardiovascular profile score (CVPS). Results: Ten fetuses with heart sparing had normal DV flow at 24–36.6 (mean 30.9) weeks of gestation. Five had growth restriction (Group 1); 4/5 had normal MPI and CVPS, and one died. Five were normally grown (Group 2); 5/5 had elevated MPI and decreased CVPS, of these 2 died in utero and one died immediately after birth despite urgent delivery. Coronary arteries were normal after birth or autopsy. Conclusions: Heart sparing confers a poor prognosis in fetal growth restriction and in normally grown fetuses with cardiac dysfunction. We suggest CA flow be assessed in all high-risk fetuses.

Fetal and Postnatal Echocardiographic Diagnosis of Ebstein Anomaly of the Mitral Valve

Ebstein anomaly of mitral valve (MV) is an extremely rare congenital heart disease. In the current report, we present a case of Ebstein of MV that was diagnosed prenatally. Fetal echocardiogram showed that the posterior leaflet of MV was tethered to the lateral wall of left ventricle (LV) with downward displacement into LV cavity. Postnatal transthoracic and transesophageal echocardiograms confirmed the diagnosis with apical displacement of the level of coaptation MV into the LV cavity. To the best of our knowledge, fetal diagnosis of Ebstein anomaly of MV has not yet been reported in the medical literature.

Coronary Sinus Defect Following Transcatheter Closure of ASD Using Amplatzer Septal Occluder: Potential Erosion by the Device

We present a case of small coronary sinus defect detected after transcatheter device closure of a large secundum atrial septal defect. Although device erosion of the dilated coronary sinus is suspected, the defect in the coronary sinus may have been present prior to ASD device closure. Dilated coronary sinus may be a risk factor when closing a secundum ASD with a device. To the best of our knowledge, coronary sinus erosion by an ASD device has not yet been reported in the medical literature.

Ductus Arteriosus Aneurysm with Organized Thrombus in a Neonate: Echocardiograms from Diagnosis to Resolution

A 7.5-lb female neonate was delivered at term, by means of a caesarian section, to a 26-year-old mother (her 2nd pregnancy). The infant had good Apgar scores but was transferred to the neonatal intensive care unit because of respiratory distress. She was treated for transient tachypnea and for bilateral spontaneous pneumothoraces. She improved with minimal respiratory support. Transthoracic echocardiography (TTE) revealed an aneurysmal ductus arteriosus (DA) with a large thrombus (Fig. 1). The patient was observed clinically and was started on 40 mg/d of aspirin. When the infant was 3 weeks old, TTE showed that the DA lumen was almost completely obliterated by the thrombus (Fig. 2). Two weeks later, TTE revealed complete resolution of the DA aneurysm and no thrombus (Fig. 3). The aspirin therapy was discontinued. Fig. 1. Transthoracic echocardiograms (parasternal short-axis views) show A) the pulmonary branch arteries and an aneurysmal ductus arteriosus with an evident thrombus (arrows); B) in color-flow Doppler mode, continuous flow through the ductus arteriosus into ... Fig. 2. Transthoracic echocardiograms. The parasternal short-axis views reveal A) the organization of the thrombus and almost complete obliteration of the ductus arteriosus lumen, and B) the absence of ductal flow, in color-flow Doppler mode. C) The suprasternal ... Fig. 3. Transthoracic echocardiograms. A) The parasternal short-axis view reveals confluent pulmonary branch arteries with unobstructed flow and complete resolution of the ductus arteriosus aneurysm and thrombus. B) The suprasternal view shows a patent aortic ...