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Published on: July 18, 2014
Cerebrovascular hemodynamics in fetuses with congenital heart disease
Tingting Man1, Yihua He1, Ying Zhao1
1Department of Ultrasound, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
Insights
Congenital heart defects (CHD) in fetuses do not consistently show the "brain sparing effect." Cerebral blood flow (MCA-PI) varies with specific heart defects, unlike the cerebroplacental ratio (CPR).
Area of Science:
- Fetal Cardiology
- Neurodevelopmental Outcomes
- Hemodynamics
Background:
- The "brain sparing effect," characterized by diminished cerebral vascular resistance, is hypothesized in fetuses with complex congenital heart defects (CHD).
- This effect's association with neurodevelopmental outcomes and its relation to specific left heart obstructive defects require further investigation.
- Understanding fetal hemodynamic changes in CHD is crucial for assessment and prognosis.
Purpose of the Study:
- To determine the impact of various left and right heart obstructive defects on fetal cerebral and placental hemodynamics.
- To evaluate the utility of these hemodynamic variables for assessing and predicting outcomes in fetuses with CHD.
Main Methods:
- Reviewed 290 fetal echocardiograms (91 CHD, 199 controls).
- Categorized CHD fetuses into left-sided obstructive lesions (LSOL), hypoplastic left heart syndrome (HLHS), right-sided obstructive lesions (RSOL), and hypoplastic right heart syndrome (HRHS).
- Measured middle cerebral artery (MCA-PI) and umbilical artery (UA-PI) pulsatility indices using Doppler, calculated Z scores, and derived the cerebroplacental ratio (CPR).
Main Results:
- No significant difference in MCA-PI between CHD groups and controls.
- MCA-PI decreased in aortic stenosis but increased in pulmonary atresia subgroups compared to controls.
- No significant difference in CPR across any study group or subgroup compared to controls.
Conclusions:
- MCA-PI variations in CHD are linked to outflow obstruction and hemodynamics, not a generalized "brain sparing effect."
- Cerebroplacental ratio (CPR) is not a sensitive indicator of CHD's impact on fetal circulation.
- Specific obstructive lesions influence MCA-PI differently, suggesting tailored prognostic assessments.
Background And Objective:
It is hypothesized that diminished cerebral vascular resistance or the "brain sparing effect" is associated with fetuses with complex congenital heart defects (CHD) and may affect their neurodevelopmental outcome. An alternative explanation is that it is related to the location, cardiac output, pressure, and resistance in left heart obstructive CHDs. We sought to determine the effects of various left and right heart obstructive defects on the cerebral and placental hemodynamics and to evaluate the utility of these variables for the assessment and prognosis of CHDs.
Methods:
A total of 290 fetal echocardiograms were reviewed, including 91 fetuses with CHD and 199 normal ones. The CHD fetuses were divided into four groups, that is, left-sided obstructive lesions (LSOL), hypoplastic left heart syndrome (HLHS), right-sided obstructive lesions (RSOL), and hypoplastic right heart syndrome (HRHS). The pulsatility index of middle cerebral artery (MCA-PI) and umbilical artery (UA-PI) were measured by pulse-wave Doppler, and their Z scores were also derived. Cerebroplacental ratio (CPR) was calculated as: CPR=MCA-PI/UA-PI.
Results:
There was no significant difference in MCA-PI between the 4 CHD and normal control groups (P>.05). However, MCA-PI and Z score decreased in aortic stenosis but not in interrupted aortic arch or coarctation subgroups, whereas they increased in pulmonary atresia but not pulmonary stenosis or tetralogy of Fallot subgroups compared with normal group (P<.05). There was no significant difference in CPR between any study group or subgroup and normal control group.
Conclusions:
Our study suggests MCA-PI is lower in aortic stenosis and high in pulmonary atresia but not significantly different in other LSOL, HLHS, RSOL, and HRHS. MCA-PI regulation in CHD is probably more associated with left and right outflow obstruction, location of the obstruction, and hemodynamics rather than "brain sparing effect" or preferential shunting of blood to the fetal brain, heart, and adrenals in the stressed fetus (eg, IUGR). CPR may not be a sensitive measure for the effect of CHDs and their severity on cerebral and placental circulation.
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