Fetal cardiovascular parameters for the prediction of postnatal cardiovascular risk in intrauterine growth-restriction?

Transcription

1 17 th International Conference on Prenatal Diagnosis and Therapy Lisbon, June 2013 Fetal cardiovascular parameters for the prediction of postnatal cardiovascular risk in intrauterine growth-restriction? Fàtima Crispi, Monica Cruz-Lemini, Brenda Valenzuela-Alcaraz, Francesc Figueras, Olga Gómez, Marta Sitges, Bart Bijnens, Eduard Gratacós Department of Maternal-Fetal Medicine, Hospital Clinic; Fetal Medicine Research Center, IDIBAPS; Barcelona, Spain ICREA, Universitat Pompeu Fabra, Barcelona, Spain Cardiology Department, Thorax Clinic Institute, Hospital Clinic,, Barcelona, Spain No disclosure

2 IMPACT OF ENVIRONMENT OPPORTUNITY FOR CORRECTION Fetus IUGR Child Low BW Adult CV Disease Myocardial infartion Hypertension Diabetes/Obesity How do we choose who to follow up into childhood? introduction Fetal life Childhood Early life Maturity Old age Barker BMJ 1995, Hecher Circulation 1995, Crispi AJOG 2008, Crispi Circulation 2010

3 Fetus 6mo Child 5yr Child To evaluate whether fetal echocardiography has a value for the prediction of postnatal cardiovascular outcome in IUGR Myocardial Performance Index Control n=100 IUGR n=100 M-mode Tissue Doppler Crispi, AJOG Cruz-Martínez, UOG Cruz-Lemini UOG Comas, AJOG Comas, AJOG Conventional Doppler Fetal Echocardiography Control n=100 Logistic Regression IUGR n=100 Blood Pressure Tissue Doppler Sphericity Index Blood Pressure Crispi, Circulation CV RISK Aortic IMT IUGR defined as EFW/birthweight <10th centile

4 Controls n= 100 Fetal Parameters IUGR n= 100 Umbilical artery PI (z-score) 0.1 ± ± 1.4 <0.001 Mean uterine artery PI (z-score) -0.7 ± ± Cerebroplacental ratio (z-score) 0.1 ± ± 1.6 <0.001 Gestational age at delivery (weeks) Descriptive Data Delivery Data 39.9 ± ± 3.5 <0.001 Birthweight centile 45 ± 23 3 ± 3 <0.001 Child Demographics Corrected age at scan (months) 6.5 ± ± IUGR: 25% abnormal postnatal CV outcome Height (cm) 68 ± 2 65 ± 3 <0.001 Weight (g) 7819 ± ± 956 <0.001 (BP >p95 + aimt >p75) Body mass index (kg/m 2 ) 16.9 ± ± PI, pulsatility index; IUGR, intrauterine growth restriction. Doppler measurements expressed in z-scores, mean ± SD. Differences estimated by Student s t test. p

5 Standard criteria OR Gestational age at delivery 1.2 ( ) Birthweight centile 1.2 ( ) Mean uterine artery PI 1.4 ( ) Umbilical artery PI 1.8 ( ) Cerebroplacental ratio 2.2 ( ) Ductus venosus PI 2.0 ( ) Aortic isthmus PI 1.0 ( ) Fetal echocardiographic parameters Right ejection fraction 0.9 ( ) Isovolumetric relaxation time 2.1 ( ) TAPSE 11.4 ( ) <0.001 Tricuspid S 7.5 (1.4 50) Right sphericity index 9.2 ( ) <0.001 Right ventricular wall (adjusted) 4.8 ( ) <0.001 PI, pulsatility index; TAPSE, tricuspid annular plane systolic excursion; S, peak systolic velocity. Right wall adjusted by cardiac transverse diameter Univariate Regressions Outcome: MBP>p95 + aimt>p95 25% p

6 Sensitivity Outcome: MBP>p95 + aimt>p95 25% Specificity GA at delivery AUC: 0.51 (95% CI , p=0.070) Birthweight centile AUC: 0.60 (95% CI , p=0.066) Umbilical artery PI AUC: 0.67 (95% CI , p=0.070) GA at delivery BW Centile Umbilical artery PI Conventional parameters: poor prediction of postnatal CV risk

7 Standard criteria OR Gestational age at delivery 1.2 ( ) Birthweight centile 1.2 ( ) Mean uterine artery PI 1.4 ( ) Umbilical artery PI 1.8 ( ) Cerebroplacental ratio 2.2 ( ) Ductus venosus PI 2.0 ( ) Aortic isthmus PI 1.0 ( ) Fetal echocardiographic parameters Right ejection fraction 0.9 ( ) Isovolumetric relaxation time 2.1 ( ) TAPSE 11.4 ( ) <0.001 Tricuspid S 7.5 (1.4 50) Right sphericity index 9.2 ( ) <0.001 Right ventricular wall (adjusted) 4.8 ( ) <0.001 PI, pulsatility index; TAPSE, tricuspid annular plane systolic excursion; S, peak systolic velocity. Right wall adjusted by cardiac transverse diameter Univariate Regressions Outcome: MBP>p95 + aimt>p95 25% p

8 Outcome: MBP>p95 + aimt>p95 25% Fetal Echocardiographic Parameters sphericity index OR 5.6 ( ) isovolumic relaxation time aorta E OR 2.4 ( ) A TAPSE OR 10.2 (4.2-36)

9 Outcome: MBP>p95 + aimt>p95 n = 25% Cardiovascular Score: TAPSE + CPR + RSI + IRT Composite CV Score AUC: 0.87 (95% CI , p<0.001) Specificity Sensitivity 90%, Specificity 77% (TAPSEz*-0.589) + (CPRz*-0.286) + (RSI*-1.938) + (IRTz*0.342) Gestational Age at Birth AUC: 0.50 (95% CI , p=0.071) Birthweight AUC: 0.59 (95% CI , p=0.066) Umbilical Artery AUC: 0.67 (95% CI , p=0.070)

10 conclusions Fetal echocardiographic parameters help identifying a high-risk group within the IUGR fetuses, which could be targeted for early screening of blood pressure, as well as for promoting healthy diet and physical exercise. Larger studies are warranted to assess clinical utility of algorithms based on fetal echocardiography to select IUGR cases with higher cardiovascular risk later in life. THANK YOU