Fetal cardiac function: what to use and does it make a difference?

Transcription

1 17 th International Conference on Prenatal Diagnosis and Therapy Lisbon, June 2013 Fetal cardiac function: what to use and does it make a difference? Fàtima Crispi Department of Maternal-Fetal Medicine, Hospital Clinic Fetal Medicine Research Center Barcelona fcrispi@clinic.ub.es No disclosure

2 fetal cardiac function Fetal disease and the heart target organ in fetal adaptation to disease Adaptive response Progressive failure Permanent Epigenetic changes CLINICAL MONITORING CARDIAC PROGRAMMING

3 cardiac function The primary function of the heart is to eject blood in order to provide adequate perfusion of organs DIASTOLE relaxation ventricular filling SYSTOLE contraction ejection of blood

4 CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION CLINICAL CARDIAC FAILURE longitudinal radial M-mode conventional Doppler tissue Doppler 2D speckle tracking 4D-STIC diastolic systolic

5 M-mode EJECTION FRACTION SYSTOLE Fraction of blood ejected from the ventricle with each heart beat LIMITATIONS Angle dependency Late-event Ejection fraction = (end diastolic ventricular volume end systolic volume) / end diastolic volume time Allan et al. B Heart J 1987, Hsieh et al. UOG 2000

6 conventional Doppler CARDIAC OUTPUT SYSTOLE Volume of blood being pumped by the ventricle per minute LIMITATIONS Variability Late-event Ao Aorta S Cardiac index (adjustement by estimated fetal weight) cardiac output = stroke voume x heart rate = 4π x (valvular diameter) 2 x (velocity time integral) x heart rate Kiserud et al. UOG 2008

7 CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION CLINICAL CARDIAC FAILURE EJECTION FRACTION CARDIAC OUTPUT diastolic systolic

8 conventional Doppler DUCTUS VENOSUS LATE DIASTOLE atrial contraction Pattern of blood during atrial contraction that indirectly reflects cardiac compliance left & right annular peak velocities (PV) left & right MPI LIMITATIONS Late-event Pulsatility index Peak systolic - minimum diastolic velocities / mean velocity Hecher et al. UOG 1996

9 conventional Doppler E/A RATIOS DIASTOLE Ratio between early (E) and late (A) ventricular filling velocity LIMITATIONS Clinical variability Interpretation A E E/A ratios Allan et al. B Heart J 1987

10 conventional Doppler MYOCARDIAL PERFORMANCE INDEX DIASTOLE SYSTOLE Sample 4-5 mm Maximum sweep Gain 60 Hz LIMITATIONS Variability Interpretation E Aortic opening Mitral closure A ICT Aorta Aorta S S ET Aortic closure Mitral opening IRT MPI = ICT + IRT ET

11 CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION CLINICAL CARDIAC FAILURE longitudinal radial myocardial motion DISPLACEMENT VELOCITY MPI E/A RATIOS EJECTION FRACTION DUCTUS VENOSUS CARDIAC OUTPUT diastolic systolic

12 M-mode & tissue Doppler MYOCARDIAL MOTION longitudinal motion mitral/tricuspid annulus (1 point) mm DISPLACEMENT cm/s VELOCITY M-mode tissue Doppler online S mm displacement MAPSE /TAPSE E A peak velocity

13 CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION CLINICAL CARDIAC FAILURE longitudinal radial motion % myocardial deformation DISPLACEMENT VELOCITY S E MPI EJECTION FRACTION diastolic E/A RATIOS DUCTUS VENOSUS systolic CARDIAC OUTPUT

14 tissue Doppler & 2D-speckle tracking MYOCARDIAL DEFORMATION Crispi et al. Fetal Diagn Therapy 2012 Deformation of a myocardial segment (2 points) tissue Doppler offline 2D speckle tracking offline (2D-strain, vvi) % strain /s strain-rate strain deformation strain-rate speed of deformation

15 CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION CLINICAL CARDIAC FAILURE longitudinal deformation radial motion % STRAIN STRAIN-RATE DISPLACEMENT VELOCITY S E MPI EJECTION FRACTION diastolic E/A RATIOS DUCTUS VENOSUS systolic CARDIAC OUTPUT

16 limitations of fetal cardiac function Fetal position Fetal movement Fetal size Fetal heart rate and high frame rate Imposibility of fetal ECG Understanding requirements and rationale Differences in algorithms/processing Fetal differences with postnatal life: Cardiomyocyte maturation Geometry/deformation Strict criteria Definition of fetal physiology Understanding limitations Application to clinical conditions Paladini 2000 Larsen 2006 Crispi 2012

17 Fetal disease and the heart target organ in fetal adaptation to disease fetal cardiac function Adaptive response Progressive failure CLINICAL MONITORING MPI and long-axis motion sensitive markers of dysfunction Permanent Epigenetic changes CARDIAC PROGRAMMING predictive of postnatal cardiovascular outcome UNDERSTANDING IMPACT OF ENVIRONMENT Fetus Child Young Mature Old FETAL PROGRAMMING

18 CHRONIC ADAPTATION conclusions SUBCLINICAL CARDIAC FAILURE CLINICAL CARDIAC FAILURE Although fetal cardiac function requires formal MOTION spectral tissue Doppler online S E A velocity (cm/s) STRAIN (%) % training and special care STRAIN-RATE with (strain/time) the acquisition and postprocessing, in experienced hands, it is feasible VELOCITY S E and reproducible. DEFORMATION color tissue Doppler offline strain (%) strain-rate (/s) STROKE VOLUME Fetal cardiac function is a promising tool for monitoring and prediction postnatal outcome CARDIAC OUTPUT EJECTION FRACTION

19 FETAL CARDIAC FUNCTION thank you