fetal cardiac function: what to use and does it make a ... · limitations of fetal cardiac function...
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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
17th International Conference on Prenatal Diagnosis and Therapy
Lisbon, June 2013
No disclosure
www.medicinafetalbarcelona.org
Fetal disease and the heart target organ in fetal adaptation to disease
Permanent Epigenetic
changes
CARDIAC
PROGRAMMING
Adaptive response
Progressive failure
CLINICAL
MONITORING
fetal cardiac function
SYSTOLE
contraction
ejection of blood
DIASTOLE
relaxation
ventricular filling
The primary function of the heart is to
eject blood in order to provide
adequate perfusion of organs
cardiac function
CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION
CLINICAL
CARDIAC FAILURE
M-mode
conventional Doppler
tissue Doppler
2D speckle tracking
4D-STIC
diastolic systolic
longitudinal radial
Allan et al. B Heart J 1987, Hsieh et al. UOG 2000
Ejection fraction = (end diastolic ventricular volume – end systolic volume) / end diastolic volume
SYSTOLE
time
M-mode
EJECTION FRACTION
Fraction of blood ejected
from the ventricle with
each heart beat
LIMITATIONS
Angle dependency
Late-event
cardiac output
= stroke voume x heart rate
= 4π x (valvular diameter)2 x (velocity time integral) x heart rate Kiserud et al. UOG 2008
Aorta S Ao
conventional Doppler
CARDIAC OUTPUT
SYSTOLE
Volume of blood
being pumped by
the ventricle
per minute
LIMITATIONS
Variability
Late-event
Cardiac index (adjustement by
estimated fetal
weight)
CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION
CLINICAL
CARDIAC FAILURE
CARDIAC OUTPUT
EJECTION FRACTION
diastolic systolic
Pulsatility index
Peak systolic - minimum diastolic velocities / mean velocity
left & right annular peak velocities (PV)
left & right MPI’
Hecher et al. UOG 1996
conventional Doppler
DUCTUS VENOSUS
LIMITATIONS
Late-event
LATE DIASTOLE
atrial contraction
Pattern of blood
during atrial
contraction that
indirectly reflects
cardiac compliance
E
A
E/A ratios
Allan et al. B Heart J 1987
DIASTOLE
conventional Doppler
E/A RATIOS
LIMITATIONS
Clinical variability
Interpretation Ratio between
early (E) and late (A)
ventricular filling
velocity
E A
Aorta S
Aorta S
Hernandez-Andrade et al. UOG 2005, Hernandez-Andrade et al. UOG 2007
DIASTOLE SYSTOLE
ICT
ET
IRT MPI =
+
Mitral closure
Aortic opening
Mitral opening
Aortic closure
ICT IRT ET
Sample 4-5 mm Maximum sweep
Gain 60 Hz
conventional Doppler
MYOCARDIAL PERFORMANCE INDEX
LIMITATIONS Variability
Interpretation
CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION
CLINICAL
CARDIAC FAILURE
CARDIAC OUTPUT
EJECTION FRACTION
diastolic systolic
E/A RATIOS
DUCTUS VENOSUS
MPI
DISPLACEMENT
VELOCITY
longitudinal radial
myocardial motion
longitudinal motion mitral/tricuspid annulus
(1 point)
mm
displacement MAPSE /TAPSE
M-mode
S’
E’ A’
peak velocity
tissue Doppler online
mm DISPLACEMENT cm/s VELOCITY
M-mode & tissue Doppler
MYOCARDIAL MOTION
CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION
CLINICAL
CARDIAC FAILURE
CARDIAC OUTPUT
EJECTION FRACTION
diastolic systolic
E/A RATIOS
DUCTUS VENOSUS
MPI
%
S’
E’
DISPLACEMENT
VELOCITY
longitudinal radial
motion myocardial
deformation
tissue Doppler offline
strain deformation
strain-rate speed of deformation
2D speckle tracking offline (2D-strain, vvi)
% strain /s strain-rate
Deformation of a myocardial segment
(2 points)
tissue Doppler & 2D-speckle tracking
MYOCARDIAL DEFORMATION
Crispi et al. Fetal Diagn Therapy 2012
CHRONIC ADAPTATION SUBCLINICAL CARDIAC DYSFUNCTION
CLINICAL
CARDIAC FAILURE
CARDIAC OUTPUT
EJECTION FRACTION
diastolic systolic
E/A RATIOS
DUCTUS VENOSUS
MPI
STRAIN STRAIN-RATE
%
S’
E’
DISPLACEMENT
VELOCITY
longitudinal radial
motion
deformation
limitations of fetal cardiac function
Paladini 2000 Larsen 2006 Crispi 2012
• 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
Fetal disease and the heart target organ in fetal adaptation to disease
Adaptive response Progressive failure
CLINICAL
MONITORING
fetal cardiac function
UNDERSTANDING
MPI and long-axis motion
sensitive markers of dysfunction
Permanent Epigenetic changes
CARDIAC
PROGRAMMING predictive of postnatal
cardiovascular outcome
Fetus Young Old Child Mature
IMPACT OF
ENVIRONMENT
FETAL PROGRAMMING
CHRONIC ADAPTATION SUBCLINICAL CARDIAC FAILURE
CLINICAL
CARDIAC FAILURE
S’
E’ A’
velocity (cm/s)
spectral tissue Doppler online
MOTION
STRAIN (%)
STRAIN-RATE (strain/time)
%
DEFORMATION
color tissue Doppler offline
strain (%)
strain-rate (/s)
S’
E’ VELOCITY
STROKE VOLUME
CARDIAC OUTPUT
EJECTION FRACTION
Although fetal cardiac function requires formal
training and special care with the acquisition and
postprocessing, in experienced hands, it is feasible
and reproducible.
Fetal cardiac function is a promising tool for
monitoring and prediction postnatal outcome
conclusions
