Mary Craft

Fetal Myocardial Deformation in Maternal Diabetes Mellitus and Obesity.

Experimental evidence suggests that changes in the fetal myocardium result from intrauterine effects of maternal diabetes mellitus and obesity. The aim of this study was to assess fetal cardiac function using two‐dimensional speckle‐tracking echocardiography to determine the effects of maternal diabetes and obesity on the fetal myocardium.

Right Atrial Deformation in Predicting Outcomes in Pediatric Pulmonary HypertensionCLINICAL PERSPECTIVE

Background— Elevated right atrial (RA) pressure is a risk factor for mortality, and RA size is prognostic of adverse outcomes in pulmonary hypertension (PH). There is limited data on phasic RA function (reservoir, conduit, and pump) in pediatric PH. We sought to evaluate (1) the RA function in pediatric PH patients compared with controls, (2) compare the RA deformation indices with Doppler indices of diastolic dysfunction, functional capacity, biomarkers, invasive hemodynamics, and right ventricular functional indices, and (3) evaluate the potential of RA deformation indices to predict clinical outcomes. Methods and Results— Sixty-six PH patients (mean age 7.9±4.7 years) were compared with 36 controls (7.7±4.4 years). RA and right ventricular deformation indices were obtained using 2-dimensional speckle tracking (2DCPA; TomTec, Germany). RA strain, strain rates, emptying fraction, and right ventricular longitudinal strain were measured. RA function was impaired in PH patients versus controls (P<0.001). There were significant associations between RA function with invasive hemodynamics (P<0.01). RA reservoir, pump function, the rate of RA filling, and atrial minimum volume predicted adverse clinical outcomes (hazard ratio [HR], 0.15; confidence interval [CI], 0.03–0.73; P<0.01; HR, 0.05; CI, 0.003–0.43; P<0.004; HR, 0.04; CI, 0.006–0.56; P<0.01; and HR, 8.6; CI, 1.6–37.2; P<0.01, respectively). Conclusions— RA deformation properties are significantly altered in pediatric PH patients. Progressive worsening of RA reservoir and conduit functions is related to changes in right ventricular diastolic dysfunction. RA reservoir function, pump function, the rate of atrial filling, and atrial minimum volume emerged as outcome predictors in pediatric PH.

SEMI-AUTOMATED QUANTIFICATION OF TRICUSPID VALVE DYNAMICS AND STRUCTURE IS FEASIBLE IN CHILDREN USING THREE-DIMENSIONAL ECHOCARDIOGRAPHY

Tricuspid regurgitation is an important risk factor for morbidity and mortality in congenital heart disease. We prospectively used three-dimensional echocardiography (3DE) to characterize the normal tricuspid valve (TV) in children focusing on geometry, structure and function of the annulus and

Depressed left and right ventricular cardiac output in fetuses of diabetic mothers

Introduction We compared right and left ventricular cardiac output (RVCO and LVCO) in fetuses of diabetic mothers (FDM) with a large normal cohort. Methods We prospectively enrolled 264 normal fetuses and 30 FDM. Fetal CO parameters such as semilunar valve velocity time integrals (AVVTI, PVVTI), ventricular outflow diameters (LVOTD, RVOTD) and stroke volumes (AVSV, PVSV) were measured, and LVCO and RVCO were calculated. These were normalized using non-linear regression to estimated fetal weight (EFW) to provide means and standard deviations. Among FDMs, mean Z scores and 95% confidence limits (CL) were calculated and compared to zero. Results LVCO, RVCO and parameters they were calculated from, increased predictably and non-linearly with increasing EFW. In FDM, LVCO was depressed (mean Z −1.679, 95% CL −2.404, −0.955, P < 0.001), and AVVTI, LVOTD and AVSV were significantly lower than normal. Similarly, RVCO (mean Z = −1.119, CL −1.839, −0.400, P = 0.003), RVOTD (mean −2.085, CL −3.077, −1.093, P < 0.001) and PVSV (mean −1.184, CL −1.921, −0.446, P = 0.003) were lower than normal, however, PVVTI was not different (mean Z 0.078, CL −0.552, +0.707, P = 0.803). Conclusion Normal biventricular stroke volumes and outputs follow a non-linear regression with EFW. FDM have significantly lower right and left heart stroke volumes and outputs for weight than do normal fetuses.

Left Ventricular Rotational and Twist Mechanics in the Human Fetal Heart

Background: The authors investigated left ventricular (LV) rotational indices, twist, and torsion in a large cohort of fetuses using two‐dimensional speckle‐tracking echocardiography. Methods: Pregnant women (N = 102) were prospectively recruited for fetal two‐dimensional speckle‐tracking echocardiography. Because of variable fetal position, ventricular orientation was established using the location of the liver and LV position in relation to the right ventricle. Twist measurements required correction to account for fetal position, reconciling directionality across all fetal orientations. Peak apical and basal rotations, global longitudinal strain, global circumferential strain (GCS), longitudinal strain rate, circumferential strain rate (CSR), twist, and torsion were reported and tested for associations with gestational age (GA) and estimated fetal weight (EFW). Results: Measurement of rotational indices was feasible in 175 examinations (73%). The mean maternal age was 31 ± 6 years, the mean GA 24 ± 6 weeks, and the EFW 1.0 ± 1.0 kg. Mean peak apical rotation, basal rotation, twist, and torsion were 9.5 ± 2.0°, −4.4 ± 1.1°, 13.1 ± 2.3°, and 7.9 ± 3.4°/cm, respectively. Mean global longitudinal strain, GCS, longitudinal strain rate, and CSR were −22.3 ± 4.3%, −25.0 ± 6.1%, −1.4 ± 0.5 sec−1, and −1.6 ± 0.5 sec−1, respectively. Absolute GCS, CSR, apical rotation, and twist declined moderately with GA and EFW (P < .05). There were strong negative nonlinear correlations of torsion with GA and EFW: torsion = 1,104 × GA−1.591 (r2 = 0.760, P < .001); torsion = 115.88 × EFW−0.427 (r2 = 0.772, P < .001). Conclusions: Determination of fetal LV rotational mechanics is feasible and reproducible using two‐dimensional speckle‐tracking echocardiography. Basal rotation, longitudinal strain, and strain rate vary little with EFW and GA. Interpretation of LV apical rotation, twist, torsion, GCS, and CSR, however, must take GA or EFW into account. These data form the basis for comparison with findings in fetuses with abnormal cardiac anatomy and function. HighlightsRotational and twist deformation was prospectively investigated using two‐dimensional speckle‐tracking in a large cohort of fetuses.Key changes in rotational and twist deformation were noted in relation to gestational age and estimated fetal weight.This data forms a basis for comparison of rotational and twist deformation to fetuses with abnormal cardiac anatomy and function.

Echocardiographic phenotype in osteogenesis imperfecta varies with disease severity

Background and objectives Our purpose was to investigate cardiovascular abnormalities in children with osteogenesis imperfecta (OI). Methods Two hundred children (100 OI, 100 matched volunteers) were prospectively studied. Aortic and left ventricular (LV) measurements were performed using transthoracic echocardiography. Patients were typed according to modified phenotypical Sillence classification as published in the Nosology and Classification of Genetic Skeletal disorders: 2015 Revision. Results Patients (age 9.6±4.1 years, body surface area 1.08±0.47 m2) consisted of OI types: 1 (n=44), 3/4 (n=54), 4 (n=1) and 15 (n=1). The 95% CIs for Zscore of aortic annulus, sinus, sinotubular junction and ascending aorta for OI were 0.43 to 0.73, 0.56 to 0.94, 0.28 to 0.70 and 0.78 to 1.24, respectively. In type 1, sinus, sinotubular junction and ascending aorta diameters were 2.29 cm, 1.81 cm and 2.05 cm, respectively, which did not differ compared with controls. The LV dimensions were larger in type 1. In type 3/4, aortic dimensions were larger than controls at all levels: annulus (1.61 vs 1.50 cm, p<0.001), sinus (2.19 vs 2.05 cm, p=0.001), sinotubular junction (1.77 vs 1.64 cm, p<0.001) and ascending aorta (1.98 vs 1.82 cm, p<0.001), but LV dimensions were normal. Conclusions Cardiovascular effects are identifiable in childhood even in mild forms of OI. Aortic dilation was the predominant finding, while valvular abnormalities were infrequent. Patients with more severe skeletal pathology (types 3/4) have more significant findings. Aortic and LV dilation in type 1 vs type 3/4 appears to differ based on the biochemical mechanism of disease.

Five-year experience with immediate extubation after arterial switch operations for transposition of great arteries

Objectives We sought to identify preoperative, intraoperative and anatomical factors associated with immediate extubation (IE) after arterial switch operation for d-transposition of great arteries (dTGA). Methods This was a single-centre retrospective study performed from 1 January 2010 to 30 June 2015. IE was defined as successful extubation in the operating room (OR). Univariate/bivariate regression of preoperative, intraoperative and anatomical variables was used to determine associations with IE. Results Of 32 patients in the dTGA spectrum (age at operation 6 days), 18 (56%) underwent IE. Twelve (71%) of the 17 patients with an intact ventricular septum and 6 (43%) of the 14 patients with ventricular septal defect (VSD) underwent IE, whereas none of the patients with double outlet right ventricle or aortic arch obstruction ( n  = 4) did. Patients who had cardiopulmonary bypass time (CPB) >173 min ( P  = 0.01), lowest temperature on CPB (T min) ≤ 30.4°C ( P  = 0.04) and aortic cross-clamp time >86 min ( P  = 0.04) were more likely to be left intubated at the end of the procedure. There was no significant difference in patients chronological age, gestational age, post-conceptual age, weight, coronary anatomy or prevalence of VSD between those who did and did not undergo IE. There was a median increase in intensive care unit (ICU) length of stay (LOS) by 1 day (33%, P  = 0.03) and ICU costs by

Relation of Right Atrial Volume, Systemic Venous Dimensions, and Flow Patterns to Right Atrial Pressure in Infants and Children

12 338 (15%, P  = 0.06) in non-IE patients. The OR turnover time ( P  = 0.09) and reintubation rate ( P  = 1) at 24 h post-extubation did not differ between those who did and did not have IE. There was no myocardial dysfunction evident on predismissal echocardiography in either group. Conclusions In this cohort of infants, post repair for TGA, 56% were extubated immediately in the OR. Greater CPB and cross-clamp times and T min ≤ 30.4°C were associated with a lesser likelihood of IE. IE was associated with shorter ICU length of stay.