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      Case Series: Fetal Pulmonary Vein A-Wave Reversal: An Early Marker of Left-Sided Cardiac Anomalies?


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          Background Improvements in congenital heart disease (CHD) screening are needed based on the lack of sensitivity of current screening methods and the understanding that the early detection of certain CHDs may improve outcomes. Fetal venous circulation has caught medical attention, and two studies demonstrated that it is feasible to register pulmonary vein flow velocity waveforms (FVWs) during early gestation. Meanwhile, the latter study proposed pulmonary vein A-wave reversal as a marker of cardiac anomaly.

          Methods We report a series of six consecutive fetuses with confirmed cardiac anomalies that underwent first-trimester screening, including pulmonary vein FVWs, at our center during 2013. CHD was confirmed by late pregnancy echocardiography, and in three cases fetal autopsies were performed.

          Result/Discussion The ductus venosus (DV) and nuchal translucency (NT) predicted 50% of CHD cases, whereas the combination of markers identified 66.6% of CHD cases. When adding pulmonary vein assessment, the rate of detection rose to 83.3%. Total five of six cases of CHD had reversal of pulmonary vein A-wave during early pregnancy. The sixth case with CHD and nonreversal of A-wave was described as right ventricle hypoplasia with type 1 tricuspid atresia and persistent ductus arteriosus.

          Conclusion This is the first series reporting pulmonary vein end-diastolic reversal as a CHD screening add-on during early pregnancy. The addition of pulmonary vein FVW assessment to the current CHD screening bundle could increase the rate detection of cardiac anomalies. This pilot study suggests that pulmonary vein end-diastolic flow reversal favors detection of left-sided CHD over the right-sided ones.

          Most cited references6

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          Contribution of fetal tricuspid regurgitation in first-trimester screening for major cardiac defects.

          To estimate the potential value of fetal assessment for tricuspid regurgitation at 11-13 weeks of gestation in the prediction of major cardiac defects.
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            Fetal venous circulation--an update on hemodynamics.

            T Kiserud (2000)
            The refinements of modern ultrasound techniques permit a renewed examination of old concepts of fetal circulation. The concept of preferential streaming of umbilical blood through the foramen ovale is verified by animal experiments, and ultrasound studies have confirmed that a similar mechanism operates in human fetuses. However, the normalized umbilical flow appears to be less in the human than in fetal sheep, and decreases with advancing gestational age (115 ml min-1 kg-1 at 20 and 64 mL min-1 kg-1 at 40 weeks). Compared to the 50% shunting of umbilical blood through the ductus venosus found in animal experiments, the degree of shunting in the human fetus under physiological conditions is considerably less, 30% at 20 weeks, which decreases to 18% at 32 weeks, suggesting a higher priority of the fetal liver than previously realized. Augmented pulsatility in the precordial veins, ductus venosus, and umbilical vein is an important clinical sign that is poorly understood. Recent fluid dynamic studies show that, apart from the pressure generated in the atria, it is the stiffness of the vessel wall, compliance, and notably, impedance which modify these waves. Particularly the substantial shift in impedance at the ductus venosus-umbilical vein junction causes wave reflection and reduced transmission of waves, the result being diminished or absent pulsation in the umbilical vein.
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              First-trimester ductus venosus screening for cardiac defects: a meta-analysis.

              Heart defects are the most common congenital abnormalities.

                Author and article information

                AJP Rep
                AJP Rep
                AJP Reports
                Thieme Medical Publishers (333 Seventh Avenue, New York, NY 10001, USA. )
                04 March 2015
                April 2015
                : 5
                : 1
                : e60-e66
                [1 ]Internal Medicine, Medicine Institute, Cleveland Clinic Foundation, Ohio
                [2 ]Centro de Estudios Perinatales, Valencia, Venezuela
                [3 ]Department of Materno-fetal Medicine, University of Tennessee, Memphis
                [4 ]Clinical Cardiology, Heart and Vascular Institute, Cleveland Clinic, Ohio
                Author notes
                Address for correspondence Aldo L. Schenone, MD Internal Medicine Residency Program Cleveland Clinic, 9500 Euclid AvenueNA 10 Cleveland, OH 44195 schenoa@ 123456ccf.org
                © Thieme Medical Publishers
                : 07 October 2014
                : 23 December 2014

                fetal pulmonary vein,congenital cardiac anomaly,congenital heart disease,first-trimester screening,fetal heart disease screening


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