Prenatal Echocardiographic Assessment of Foramen Ovale Appearance in Fetuses with <smlcap>D</smlcap>-Transposition of the Great Arteries and Impact on Neonatal Outcome

Abstract

Introduction: Neonates with <smlcap>D</smlcap>-transposition of the great arteries (dTGA) may die at birth because of the inadequate intracardiac mixing due to a misdiagnosed restrictive foramen ovale. We reviewed our experience in echocardiographic assessment and perinatal management of fetuses with dTGA searching for new features that may predict the need for urgent balloon atrial septostomy (BAS) immediately after birth. Patients and Methods: We included fetuses diagnosed with dTGA between January 2000 and December 2014. We assessed pre- and postnatal appearance of the foramen ovale, ductus arteriosus and pulmonary veins. Both the diagnostic findings at the time of last prenatal echocardiogram and those findings deriving from a retrospective reevaluation of stored videos were considered. BAS was defined as urgent if performed in neonates with restrictive foramen ovale and severe hypoxemia. Results: We reviewed 40 fetuses with dTGA. 20/40 fetuses received urgent BAS at birth. Not only the restrictive but also the hypermobile and the redundant appearance of the foramen ovale was significantly associated with urgent BAS (p < 0.0001, p = 0.002 and p = 0.0001, respectively). Conclusions: Prenatal evaluation of the foramen ovale appearance in fetuses with dTGA is still challenging. Based on our experience, also the redundant foramen ovale appearance may need urgent BAS at birth.

Redundancy of foramen ovale flap may mimic fetal aortic coarctation

“…The foramen ovale flap (FOF), which derives primarily from the septum primum, partially covers this interatrial communication. The FOF has been defined as redundant (RFOF), in the context of fetal congenital heart disease (CHD), when it herniates into the left atrium for more than 50% of the left atrial diameter 2,4 . In normal fetal hearts, a RFOF has been reported to occur in roughly one third of the cases with a restrictive FO 7 .…”

Can fetal echocardiograms reliably predict the need for urgent balloon atrial septostomy in transposition of the great arteries?

“…Three other retrospective case-series studies that examined possible predictors of urgent BAS using different fetal echocardiography markers in neonates with TGA were identified. Tuo et al 2 demonstrated restrictive FO or hypermobile or redundant septum primum was significantly associated with the need for urgent BAS. Punn and Silverman3 also examined the morphology and function of FO, and ductal size and shunting pattern.…”

“…The following terms were used: exp ‘INFANT, NEWBORN’/OR (newborn * OR neonates*) AND exp ‘HEART DETECTS, CONGENITAL’/OR (congenital heart AND (defect* OR malformation*)) AND exp ‘ULTRASONOGRAPY, PRENATAL’/OR ((prenatal OR antenatal) AND (ultrasonography OR ultrasound OR scan)) OR (echocardiogram OR echocardiograph*, OR ‘cardiac echo’) AND exp FETUS/OR exp ‘FETAL RESEARCH’/OR ((fetal OR foetal OR fetus OR fetus OR prenatal OR antenatal) AND echocardiog*) AND (‘Balloon atrial septostomy’ OR atrial septostomy), OR Balloon atrial septostomy OR atrioseptostomy). In total, 31 publications were identified, in which 4 studies were relevant on further review 1–4. All 4 studies included newborns with an antenatal diagnosis of TGA.…”

“…However, predicting which patients will need an urgent BAS on fetal echocardiogram is challenging. BAS is performed in the presence of significant hypoxaemia (preductal saturations ≤70%), despite prostaglandin therapy and invasive ventilatory support, with echocardiographic demonstration of restrictive interatrial communication preventing circulatory mixing 1–4…”

Right heart dilatation in a fetus with an abnormal foramen ovale valve: an indicator of interatrial communication restriction

“…The case group was selected from cases in which the FO valve had a shape or motion abnormality. The FO valve was diagnosed as a shape abnormality when it appeared to be either aneurysmal or hypermobile as previously described [11][12][13]; or motion abnormality, when it appeared to be thick and flat without a "flapping" motion normally seen in the uterus [14,15]. The cases diagnosed with congenital heart diseases or with no clear images were excluded.…”