To determine the outcomes fetuses presenting with significant RV greater than LV disproportion without structural congenital heart disease (CHD). In a retrospective case series study, we reviewed fetal comprehensive cardiovascular echocardiography on 6 singleton pregnancies who were referred for significant and obvious RV > LV disproportion. All fetuses had normal veno-atrial, atrio-ventricular and ventriculo-arterial connections and alignments. There was no evidence of coarctation in any fetus. None had evidence of stenosis or insufficiency at any valve. There was no ductal constriction and no atrial or ventricular septal defects. No arterio-venous malformations or fistulae were detected from the placenta to the peripheral vasculature by color Doppler in any of the fetuses. However, in each fetus a redundancy of the septum primum or flap of the foramen ovale was seen in the left atrium to partially cover the orifice of the mitral valve. 6 third trimester AGA fetuses were identified as having RV 2 times greater than the LV size with normal measurements for the mitral valve, aortic valve transverse aortic arch and distal aortic arch proximal to the ductus arteriosus. The tricuspid valve, RV diameters and pulmonary valves were top normal against our institutional nomograms. There was mildly increased flow across the tricuspid and pulmonary valves and mildly decreased flow across the mitral and aortic valves. Cardiac circumferences to thoracic circumference ratios were within normal limits. After delivery, none of the fetuses had evidence of coarctation. RV greater than LV disproportion may be seen with structural CHD with relative hypoplasia of the right or left heart and with atrio-venous malformations. When no evidence of CHD exists, we recommend close evaluation of the flap of the septum primum to look for partial obstruction of the mitral valve orifice. We further recommend post-natal follow up to rule out coarctation of the aorta.

Conclusions: Women presenting for FEcho report high anxiety levels irrespective of whether a fetal anomaly already has been diagnosed.Clinician awareness and sensitivity is recommended and further investigation of anxiety modifiers in this high risk group should be explored.

To demonstrate the combined Doppler and m-mode findings in fetuses with benign ventricular arrhythmias. Three fetuses referred to cardiovascular echocardiography for fetal arrhythmias were found to have benign ventricular arrhythmias. High resolution magnified m-mode ultrasound images through the atrial wall and aortic valve, through the atrial wall and a ventricular wall and across both ventricles with movement of at least one atrio-venous valve were used to make the diagnoses. Evaluation by pulsed Doppler of peripheral combined venous and arterial structures such as the inferior vena cava and descending aorta and the right or left pulmonary artery and veins were used to confirm the diagnoses. Between March 2007 and January 2009, three cases of fetal ventricular ectopy were diagnosed: ventricular premature contractions (PVCs), ventricular bigeminy and intermittent ventricular tachycardia (IVT). Evaluation of the umbilical artery or across the outflow tracts or ductus arteriosus showed the nature of the arrhythmia but not whether they were ventricular or atrial in origin. The fetuses with PVCs and ventricular bigeminy were managed expectantly in utero, but the fetus with IVT was delivered the day after diagnosis at 37 + 2/7 weeks. By 3 months after delivery, none of the newborns showed any ectopy. Premature atrial contractions are common in fetuses but may become problematic when frequent as in bigeminy or intermittent tachycardia, but ventricular arrhythmias are rare (< 0.5% of all fetal arrhythmias). M-mode measurements combined with Doppler measurements of the atrium to ventricular or ventricular to atrium conduction times are necessary to provide a diagnosis and prognosis. We recommend a full electrocardiogram after delivery and a long term monitor recording prior to discharge in these cases.

To demonstrate that the diameter of the fetal ductus venosus increases in size from quiescent to active fetal movement states. In a prospective cross sectional study, fetuses found to be within normal limits were assessed for their activity states at the time of imaging and pulsed Doppler measurements of the DV. All Doppler pulsatility measurements were within our normal limits of < 1.0 and measured less than 2.5 mm at the narrowest internal diameter of the DV. Activity levels were divided into quiet and moving states by consensus of the fetal echo team of at least two sonographers and all cases were digitally recorded. Criteria for moving were established as active body movements, breathing movements and hiccups with reactive movements. The DV was identified by HD color Doppler aliasing in the DV; the color scale was then increased and the color gain reduced until the echogenic surfaces of the DV could be observed with near transparent color flow. Measurements of the DV were made in two groups: group A had 205 fetuses in a near constant state of motion and group Q had 412 fetuses without apparent gross or breathing movements. Fetal heart rates were greater in the active fetuses. DV PI in both groups were within normal limits. The mean diameters in active fetuses across gestation was significantly larger in the active fetuses (p = 0.001) but the mean measurements of both groups across gestation were within our normal measurements nomograms. The DV PI does not change significantly with fetal activity. The DV size increases significantly within the normal range during normal activity. The DV diameter seems to rapidly change size in order to accommodate the changing oxygen requirements of the fetus during different activity states by altering the percent of umbilical venous blood flow shunted toward the heart. This suggests that the DV is actively regulated by the increased needs of myocardium and skeletal muscle during fetal activity.

To determine the ease and reproducibility of Tei and LVSF parameters in fetuses undergoing echocardiography across gestation In a prospective cross sectional study, we observed the time to completion and ability to achieve adequate images by well trained fetal cardiology research fellows for LVSF and for the Tei index. Measurements performed by three research fellows were compared to those of the primary echocardiographer for each fetal echocardiogram (average 3 minutes to 1 minute for Tei index and 12 to 2 minutes for LVSF). The LVSF was calculated from the formula: LV diastolic dimension—LV systolic dimension/LV diastolic dimension. The Tei index was determined by measurement of isovolumetric contraction time + the isovolumetric relaxation time/systolic ejection time. The time to completion and adequate imaging of 600 consecutive fetal echocardiograms were available for study. Excluded from the study were fetuses with single ventricle and those with persistent tachyarrhythmias, but included those with intermittent arrhythmias and multiple gestations. Adequate m-mode images were obtained in 3 of 42 fetuses < 16 weeks and 4 of 35 fetuses > 35 weeks by the fellows. Adequate Tei measurements were completed in all fetuses by the fellows and were within 5% of the measurements made by the primary echocardiographer. Fellows were able to obtain adequate m-mode images in 14% of women with a BMI > 40. Fellows were able to obtain Tei measurements in 100% of women with a BMI > 40. M-mode measurements in fetuses remain difficult and require a long learning curve. M-mode measurements in fetuses less than 16 weeks and over 35 weeks as well as in obese mothers are particularly difficult. The Tei index in the same cohort of patients appears to be consistently measurable and more easily learned in difficult to image pregnancies

We sought to compare two methods of estimation of fetal myocardial function across gestation from our database of normal fetuses. In a retrospective cross sectional study, we compared left ventricular shortening fraction (LVSF) from m-mode ultrasound and pulsed Doppler ultrasound timing of flow patterns from the left ventricular outflow tract to determine the myocardial performance (Tei) index. The LVSF was calculated from the formula: LVDD-LVSD/LVDD. All measurements were taken in the lower third of the LV below the mitral valve when the m-mode line of insonation was perpendicular to the ventricular septum. The Tei index measured the specific systolic time intervals created by the movement of the anterior leaflet of the mitral valve and the aortic valve leaflets within the pulsed Doppler sample placed over and parallel to flow in the LV outflow tract. The Tei index utilized the “clicks” method where the spike artifacts (clicks) in the Doppler signal were used to measure isovolumetric contraction time (ICT), systolic ejection time (LVET) and isovolumetric relaxation time (IRT). The Tei index was determined from the formula: ICT + IRT/ LVET. 3200 fetal echocardiograms performed over a 4 year period were available for review of the LV function parameters of LVSF and Tei index. Normal LVSF from m-mode measurements across gestation remains linear and constant from 11 weeks until term at 0.41 (+/− 0.12). LV myocardial performance using the TEI index increases in a linear fashion over gestation from 11 weeks gestation to term from 0.4 to 0.58 (+/− 0.05). The LVSF in fetuses has been the standard method of functional evaluation, but numbers may vary from center to center based on the interpretation of where to measure the systolic and diastolic dimensions and may have a wide standard deviation at various fetal ages. The Tei index using the “clicks” method in the same cohort of patients appears to have a tighter standard deviation and may be more reproducible.