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Published on: May 5, 2018
Cerebral blood flow characteristics and biometry in fetuses undergoing prenatal intervention for aortic stenosis with
Doff B McElhinney1, Carol B Benson, David W Brown
1Department of Cardiology, Children's Hospital Boston, and Pediatrics, Harvard Medical School, Boston, MA, USA. doff.mcelhinney@cardio.chboston.org
Insights
Children with hypoplastic left heart syndrome (HLHS) show abnormal fetal cerebral blood flow. Prenatal aortic valvuloplasty did not significantly alter these cerebral hemodynamic profiles in fetuses with evolving HLHS.
Area of Science:
- Cardiovascular Physiology
- Fetal Medicine
- Neurodevelopmental Pediatrics
Background:
- Hypoplastic left heart syndrome (HLHS) is linked to neurodevelopmental dysfunction in children.
- Prenatal factors, including altered in utero cerebral hemodynamics, may contribute to these neurodevelopmental risks.
- Abnormal cerebral blood flow profiles are observed in fetuses with HLHS.
Purpose of the Study:
- To evaluate the impact of prenatal aortic valvuloplasty on cerebral blood flow and head circumference in fetuses with evolving HLHS.
- To assess changes in middle cerebral artery (MCA) pulsatility index (PI) and resistive index (RI) following intervention.
- To investigate potential correlations between prenatal hemodynamic changes and neurodevelopmental outcomes.
Main Methods:
- Seventy fetuses with evolving HLHS underwent prenatal aortic valvuloplasty.
- Cerebral blood flow was assessed using MCA PI and RI Z-scores before and after intervention.
- Fetal head circumference and umbilical artery PI/RI Z-scores were also monitored.
Main Results:
- Abnormal MCA PI and RI Z-scores were noted in fetuses with evolving HLHS, indicating low cerebral vascular impedance.
- Prenatal aortic valvuloplasty did not lead to significant changes in MCA PI and RI Z-scores during early or late gestation follow-up.
- Fetal head circumference and umbilical artery PI/RI Z-scores remained within normal ranges.
Conclusions:
- Mid-gestation fetuses with evolving HLHS exhibit abnormal cerebral blood flow characteristics.
- The underlying mechanisms and clinical significance of these prenatal hemodynamic abnormalities require further investigation.
- Prenatal aortic valvuloplasty, while feasible, did not demonstrate a major impact on the assessed cerebral blood flow indices in this cohort.
Abstract:
Children with hypoplastic left heart syndrome (HLHS) are at risk for neurodevelopmental dysfunction; prenatal factors may play a role in this predilection. Cerebral blood flow profiles are abnormal in fetuses with HLHS, raising the possibility that cerebral hemodynamics in utero may be related to neurodevelopmental abnormalities. Prenatal aortic valvuloplasty for fetal aortic stenosis with evolving HLHS is technically feasible and improves left heart hemodynamics. This study aimed to assess the effects of prenatal intervention on cerebral blood flow profiles and head circumference in fetuses with evolving HLHS. Seventy fetuses underwent prenatal aortic valvuloplasty for evolving HLHS (median 23 weeks gestation). Among 46 fetuses that had successful valvuloplasty and available data, middle cerebral artery (MCA) pulsatility (PI) and resistive (RI) indices were abnormal (Z-scores -1.7+/-1.1 and -2.2+/-1.4, p<0.001). Early post-valvuloplasty (n=33) and at late gestation follow-up (n=28), MCA PI and RI Z-scores remained low with no difference from pre- or early postintervention. Fetal head circumference was normal, as were umbilical artery PI and RI Z-scores. Cerebral blood flow characteristics are abnormal in mid-gestation fetuses with evolving HLHS, suggesting low cerebral vascular impedance. The mechanisms and significance of these abnormalities are unknown. Prenatal aortic valvuloplasty did not have a major impact on these indices. (E-mail: doff.mcelhinney@cardio.chboston.org).
