Diagnosis and management of restricted or closed foramen ovale in fetuses with congenital heart disease

Donofrio, Mary T.; Bremer, Yvonne A; Moskowitz, William B.

doi:10.1016/j.amjcard.2004.07.133

Cited by 29 publications

(27 citation statements)

References 14 publications

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“…Management of these fetuses, who are at significant risk of compromise with foramen ovale restriction or closure, can benefit from coordination of care in the delivery room. 175,176,481,547,572,584,585,[588][589][590][591][592][593][594] Fetuses with HLHS identified to have a severely restrictive or intact atrial septum are at increased risk for compromise in the delivery room if fetal pulmonary vein flow shows significant reversed flow suggesting severe left atrial hypertension in the third trimester. 175,176,481,549,572 In 2 studies, 176,481 the ratio of pulmonary vein forward to reversed velocity-time integral was used to determine potential need for intervention.…”

Section: Foramen Ovale-dependent Lesionsmentioning

confidence: 99%

Diagnosis and Treatment of Fetal Cardiac Disease

Donofrio¹,

Moon-Grady²,

Hornberger³

et al. 2014

Circulation

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979

543

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Background— The goal of this statement is to review available literature and to put forth a scientific statement on the current practice of fetal cardiac medicine, including the diagnosis and management of fetal cardiovascular disease. Methods and Results— A writing group appointed by the American Heart Association reviewed the available literature pertaining to topics relevant to fetal cardiac medicine, including the diagnosis of congenital heart disease and arrhythmias, assessment of cardiac function and the cardiovascular system, and available treatment options. The American College of Cardiology/American Heart Association classification of recommendations and level of evidence for practice guidelines were applied to the current practice of fetal cardiac medicine. Recommendations relating to the specifics of fetal diagnosis, including the timing of referral for study, indications for referral, and experience suggested for performance and interpretation of studies, are presented. The components of a fetal echocardiogram are described in detail, including descriptions of the assessment of cardiac anatomy, cardiac function, and rhythm. Complementary modalities for fetal cardiac assessment are reviewed, including the use of advanced ultrasound techniques, fetal magnetic resonance imaging, and fetal magnetocardiography and electrocardiography for rhythm assessment. Models for parental counseling and a discussion of parental stress and depression assessments are reviewed. Available fetal therapies, including medical management for arrhythmias or heart failure and closed or open intervention for diseases affecting the cardiovascular system such as twin–twin transfusion syndrome, lung masses, and vascular tumors, are highlighted. Catheter-based intervention strategies to prevent the progression of disease in utero are also discussed. Recommendations for delivery planning strategies for fetuses with congenital heart disease including models based on classification of disease severity and delivery room treatment will be highlighted. Outcome assessment is reviewed to show the benefit of prenatal diagnosis and management as they affect outcome for babies with congenital heart disease. Conclusions— Fetal cardiac medicine has evolved considerably over the past 2 decades, predominantly in response to advances in imaging technology and innovations in therapies. The diagnosis of cardiac disease in the fetus is mostly made with ultrasound; however, new technologies, including 3- and 4-dimensional echocardiography, magnetic resonance imaging, and fetal electrocardiography and magnetocardiography, are available. Medical and interventional treatments for select diseases and strategies for delivery room care enable stabilization of high-risk fetuses and contribute to improved outcomes. This statement highlights what is currently known and recommended on the basis of evidence and experience in the rapidly advancing and highly specialized field of fetal cardiac care.

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Section: Foramen Ovale-dependent Lesionsmentioning

confidence: 99%

Diagnosis and Treatment of Fetal Cardiac Disease

Donofrio¹,

Moon-Grady²,

Hornberger³

et al. 2014

Circulation

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979

543

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“…The 2 fetuses that developed DA constriction were at the most mature end of the gesta- tional age spectrum, which is consistent with reported data concerning the risk of indomethacin-induced DA constriction [23] . DA constriction in the fetus is well described, with the majority of cases occurring in one of two clinical situations: (1) in otherwise normal pregnancies where the mother has taken NSAIDs or the cause is unknown [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]24] , and (2) in fetuses that have undergone fetal surgical procedures, where the DA has been shown to be reversible [25,26] . What makes the DA constriction in these two patients particularly significant was their cardiac diagnosis.…”

Section: Discussionmentioning

confidence: 99%

Reversible Ductus Arteriosus Constriction due to Maternal Indomethacin after Fetal Intervention for Hypoplastic Left Heart Syndrome with Intact/Restrictive Atrial Septum

Vogel

Wilkins‐Haug²,

McElhinney³

et al. 2009

Fetal Diagn Ther

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Objective:Fetal cardiac intervention (FCI) has been performed at our center in selected fetuses with complex congenital heart disease since 2000. Most interventions are performed in fetuses with a ductus arteriosus (DA)-dependent circulation. Indomethacin promotes closure of the DA in newborns and in fetal life, a potentially life threatening complication in fetuses with ductus-dependent congenital heart disease. Methods:We reviewed our experience with FCI with a focus on the frequency, features, and clinical course of ductal constriction. Fetuses undergoing FCI receive comprehensive pre- and postoperative cardiac and cerebral ultrasound evaluation, approximately 24 hours before and after the procedure, including imaging of DA flow and Doppler assessment of the umbilical artery and vein, ductus venosus, and, since 2004, the middle cerebral artery. Results:Among 113 fetuses that underwent FCI, 24 of which were older than 28 0/7 weeks gestation, 2 were found to have DA constriction due to indomethacin therapy within 24 hours of intervention. Both of these were 30-week fetuses with hypoplastic left heart syndrome and restrictive or intact atrial septum. The DA was stenotic by spectral and color Doppler, and middle cerebral and umbilical artery pulsatility indexes were depressed. After discontinuation of indomethacin, the Doppler indices improved or normalized. Conclusion:Close echocardiographic monitoring of fetal Doppler flow velocities is very important after fetal intervention and indomethacin treatment, as the consequences of DA constriction in a fetus with hypoplastic left heart syndrome are potentially lethal. Sonographic evaluation should include measurement of cerebral and umbilical arterial flow velocities as well as color and spectral Doppler interrogation of the DA.

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“…Phillipos et al have followed the FO in fetuses between 20 and 38 weeks of gestation and reported that the increase in the diameter of FO is directly proportional to the number of gestational weeks [25]. According to some studies, fetuses with subnormal FO diameters may experience altered fetal hemodynamics (blood flow in umbilical vein, DV and vena cava inferior) leading to hemodynamic disorders ranging from mild right-sided cardiac failure to severe hydrops fetalis [26][27][28]. On the other hand, increased FO diameter has been associated with atrial septal defect (ASD) in postnatal life.…”

Section: Discussionmentioning

confidence: 99%

Can abnormal ductus venosus peak velocity index for veins in normal fetuses predictfailure of functional closure of the foramen ovale in the postnatal period?

Yozgat

Avci²,

Kilic

et al. 2015

Med Ultrason

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Aim: To investigate whether ductus venosus (DV) wave velocities and/or DV peak velocity index for veins (DV-PVIV) can predict failure of functional closure of the foramen ovale in the postnatal period. Material and methods: Fetal echocardiography was performed in 455 healthy women with uneventful pregnancies between the 20-24 th gestational weeks. DV blood flow and DV-PVIV data were collected prospectively. Echocardiography was repeated in healthy subjects on the 30 th postnatal day. Four hundred patients met the study criteria. Newborns with clearly visible foraminal flaps, interatrial septal defects smaller than 5 mm and right-to-left shunting through the defect were accepted as patent foramen ovale (PFO) (n=91). Newborns without PFO (n=309) comprised the control group. Results: A statistically significant difference was detected between the groups with and without PFO in terms of mean DV-PVIV values, DV-D and DV-a wave velocities (p<0.05 for all). ROC analysis showed that increased DV-PVIV values were related to and predictive of PFO (AUC=0.75; p<0.001) and that a threshold value of 0.62, had a sensitivity of 86.8% (95% CI 78.1-93.0%) and a specificity of 51.7% (95% CI 46.1-57.5%). Conclusion: DV-PVIV values above 0.62 at the time of fetal echocardiographic examination can predict failure of functional closure of the foramen ovale in the postnatal period.

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Diagnosis and management of restricted or closed foramen ovale in fetuses with congenital heart disease

Cited by 29 publications

References 14 publications

Diagnosis and Treatment of Fetal Cardiac Disease

Diagnosis and Treatment of Fetal Cardiac Disease

Reversible Ductus Arteriosus Constriction due to Maternal Indomethacin after Fetal Intervention for Hypoplastic Left Heart Syndrome with Intact/Restrictive Atrial Septum

Can abnormal ductus venosus peak velocity index for veins in normal fetuses predictfailure of functional closure of the foramen ovale in the postnatal period?

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