BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Déu), Barcelona, Spain.
Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.
Ultrasound Obstet Gynecol. 2020 Dec;56(6):837-849. doi: 10.1002/uog.21970. Epub 2020 Nov 12.
Coarctation of the aorta (CoA) is associated with left ventricular (LV) dysfunction in neonates and adults. Cardiac structure and function in fetal CoA and cardiac adaptation to early neonatal life have not been described. We aimed to investigate the presence of cardiovascular structural remodeling and dysfunction in fetuses with CoA and their early postnatal cardiac adaptation.
This was a prospective observational case-control study, conducted between 2011 and 2018 in a single tertiary referral center, of fetuses with CoA and gestational age-matched normal controls. All fetuses/neonates underwent comprehensive echocardiographic evaluation in the third trimester of pregnancy and after birth. Additionally, myocardial microstructure was assessed in one fetal and one neonatal CoA-affected heart specimen, using synchrotron radiation-based X-ray phase-contrast microcomputed tomography and histology, respectively.
We included 30 fetuses with CoA and 60 gestational age-matched controls. Of these, 20 CoA neonates and 44 controls were also evaluated postnatally. Fetuses with CoA showed significant left-to-right volume redistribution, with right ventricular (RV) size and output dominance and significant geometry alterations with an abnormally elongated LV, compared with controls (LV midventricular sphericity index (median (interquartile range; IQR), 2.4 (2.0-2.7) vs 1.8 (1.7-2.0); P < 0.001). Biventricular function was preserved and no ventricular hypertrophy was observed. Synchrotron tomography and histological assessment revealed normal myocyte organization in the fetal and neonatal specimens, respectively. Postnatally, the LV in CoA cases showed prompt remodeling, becoming more globular (LV midventricular sphericity index (mean ± SD), 1.5 ± 0.3 in CoA vs 1.8 ± 0.2 in controls; P < 0.001) with preserved systolic and normalized output, but altered diastolic, parameters compared with controls (LV inflow peak velocity in early diastole (mean ± SD), 97.8 ± 14.5 vs 56.5 ± 12.9 cm/s; LV inflow peak velocity in atrial contraction (median (IQR), 70.5 (60.1-84.9) vs 47.0 (43.0-55.0) cm/s; LV peak myocardial velocity in atrial contraction (mean ± SD), 5.1 ± 2.6 vs 6.3 ± 2.2 cm/s; P < 0.05). The neonatal RV showed increased longitudinal function in the presence of a patent arterial duct.
Our results suggest unique fetal cardiac remodeling in CoA, in which the LV stays smaller from the decreased growth stimulus of reduced volume load. Postnatally, the LV is acutely volume-loaded, resulting in an overall geometry change with higher filling velocities and preserved systolic function. These findings improve our understanding of the evolution of CoA from fetal to neonatal life. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
主动脉缩窄（CoA）与新生儿和成人的左心室（LV）功能障碍有关。胎儿 CoA 的心脏结构和功能以及心脏对新生儿早期生命的适应尚未被描述。我们旨在研究 CoA 胎儿存在心血管结构重塑和功能障碍及其新生儿早期的心脏适应。
这是一项前瞻性观察性病例对照研究，于 2011 年至 2018 年在一家三级转诊中心进行，纳入了 CoA 胎儿和胎龄匹配的正常对照组。所有胎儿/新生儿在妊娠晚期和出生后均接受全面的超声心动图评估。此外，使用基于同步辐射的 X 射线相衬微计算机断层扫描和组织学，分别在一个 CoA 受累胎儿和一个新生儿心脏标本中评估心肌微观结构。
我们纳入了 30 例 CoA 胎儿和 60 例胎龄匹配的对照组。其中，20 例 CoA 新生儿和 44 例对照组也在出生后进行了评估。与对照组相比，CoA 胎儿表现出明显的左右心室容量重新分布，右心室（RV）大小和输出占主导地位，LV 几何结构发生明显改变，呈异常伸长（LV 中室间隔球形指数（中位数（四分位距；IQR），2.4（2.0-2.7）与 1.8（1.7-2.0）；P < 0.001）。双心室功能正常，无心室肥厚。同步加速器断层扫描和组织学评估分别显示胎儿和新生儿标本中正常的心肌组织排列。出生后，CoA 病例的 LV 迅速重塑，变得更加球形（LV 中室间隔球形指数（平均值±标准差），CoA 为 1.5±0.3，对照组为 1.8±0.2；P < 0.001），收缩功能正常，但与对照组相比，舒张功能参数发生改变（LV 早期舒张期流入速度峰值（平均值±标准差），97.8±14.5 与 56.5±12.9 cm/s；LV 心房收缩期流入速度峰值（中位数（IQR），70.5（60.1-84.9）与 47.0（43.0-55.0）cm/s；LV 心房收缩期心肌速度峰值（平均值±标准差），5.1±2.6 与 6.3±2.2 cm/s；P < 0.05）。新生儿 RV 在动脉导管未闭的情况下表现出纵向功能增加。
我们的研究结果表明 CoA 存在独特的胎儿心脏重塑，其中 LV 因容量负荷减少而生长刺激减少，体积较小。出生后，LV 迅速受到容量负荷，导致整体几何形状改变，充盈速度增加，收缩功能正常。这些发现提高了我们对 CoA 从胎儿到新生儿生命的演变的理解。版权所有 © 2020 ISUOG。由 John Wiley & Sons Ltd 出版。
