Innovative study of the fetal heart in monochorionic multiple births

Introduction. Fetal echocardiography is currently one of the main methods of prenatal diagnosis. However, in recent years, attention has shifted towards the use of ultrasound to assess fetal myocardial function.

The aim of this study is compare global longitudinal deformation of the myocardium of the left (LV) and right ventricles (RV) of the heart in fetuses with uncomplicated singleton pregnancy, in fetuses from monochorionic twins with transfusion syndrome, selective growth retardation and in uncomplicated monochorionic multiple pregnancy.

Material and methods. A prospective cohort study was conducted which included 60 pregnant patients: Group I — patients with an uncomplicated singleton pregnancy (n=25); Group II — 35 patients with monochorionic diamniotic twins, whose pregnancy in 10 cases was complicated by feto-fetal transfusion syndrome (stages I-III according to Quintero R.A.), in 10 cases — selective growth retardation of the second fetus and in 15 cases monochorionic twins without complications. The following parameters were determined: global longitudinal deformation (GLD) of the myocardium of the ventricles of fetal hearts using the speckle tracking method of ejection fraction (EF), end-diastolic and end-systolic volumes of the ventricles of the heart.

Results. Significant differences were established in GLD of RV and LV between singleton and monochorionic multiple pregnancies (LV: -21.2 ± 2.03 versus -23.41 ± 0 .25, p = 0.003); RV: — 20.3 ± 2.5 versus -23.3 ± 2.5, p = 0.013). Significant differences were revealed in GLD of the LV and RV in recipient fetuses before and after laser coagulation of placental anastomoses (LPCA) [LV in recipients before LCPA (- 20.4 ± 2.98) versus LV recipient after LCPA (-24.2 ± 3.3), p = 0.018], [RV in recipients before LKPA (- 20.4 ± 2.8) vs. RV in recipients after laser coagulation of placental anastomoses (-23.7 ± 3.4, p = 0.012].

Conclusion. Assessment of the cardiac function of fetuses from monochorionic twins using the echocardiographic speckle tracking technique makes it possible to identify early changes in fetal myocardial function in twins from monochorionic diamniotic twins, as well as to carry out reliable testing monitoring changes in cardiac function over time.

1. Crispi F, Sepulveda-Swatson E, Cruz-Lemini M, et al. Feasibility and reproducibility of a standard protocol for 2D speckle tracking and tissue doppler analysis of fetal heart strain and strain rate. Fetal Diagnostics. 2012; 32: 96–108. https://doi.org/10.1159/000337329

2. Crispi F, Gratakos E. Fetal cardiac function: technical aspects and potential research and clinical applications. Fetal Diagnostics. 2012; 32:47–64. https://doi.org/10.1159/000338003

3. Godfrey ME, Messing B, Valsky D, et al. Fetal cardiac function: M-mode and correlation of 4D spatiotemporal imaging. Fetal Diagnostics. 2012; 32:17-21. https://doi.org/10.1159/000335357

4. Godfrey ME, Messing B, Cohen SM, et al. Functional assessment of the fetal heart: a review. Ultrasound Obstet Gynecol. 2012; 39:131–144. https://doi.org/10.1002/uog.9064

5. Hernandez-Andrade E, Benavidez-Serralde JA, Cruz-Martinez R, et al. Evaluation of standard fetal heart function doppler parameters: E/A ratio, outflow tracts, and myocardial performance index. Fetal Diagnostics. 2012; 32:22–29. https://doi.org/10.1159/000330792

6. Shah AM, Solomon SD. Visualization of myocardial deformity: state of the art and perspectives. Circulation. 2012; 125 : 244–248 . https://doi.org/10.1161/CIRCULATIONAHA.111.086348

7. Blessberger H, Binder T. Non-invasive imaging: two-dimensional speckle-tracking echocardiography: fundamentals. Heart. 2010; 96:716–722. https://doi.org/10.1136/hrt.2007.141002

8. D’Huge J, Heimdal A, Jamal F, et al. Regional strain and strain rate measurements with cardiac ultrasound: principles, implementation, and limitations. Eur J Echocardiog. 2000; 1 : 154–170. https://doi.org/10.1053/euje.2000.0031

9. Mirea O, Duchenne J, Voigt Y. Recent advances in echocardiography: visualization of strain and strain rate. F1000Res. 2016; 5:787. https://doi.org/10.12688/f1000research.7228.1

10. Germanakis I, Gardiner H. Assessing fetal myocardial deformity using speckle tracking techniques. Fetal Diagnostics. 2012; 32:39-46. https://doi.org/10.1159/000330378

11. Bijnens B, Cikes M, Butakoff C, et al. Myocardial movement and deformation: what does it tell us and how does it relate to function? Fetal Diagnostics. 2012; 32:5-16. https://doi.org/10.1159/000335649

12. Leitman M, Lysyansky P, Sidenko S, et al. 2D strain is a new software for real-time quantitative echocardiographic assessment of myocardial function. J Am Soc Echocardiog. 2004; 17:1021–1029. https://doi.org/10.1016/j.echo.2004.06.019

13. Rychik J, Zeng S, Bebbington M, et al. Speckle-tracking imaging of myocardial deformity in intertwin transfusion syndrome: differences in deformity and strain rate between donor and recipient twins. Fetal Diagnostics. 2012; 32:131–137. https://doi.org/10.1159/000335403

14. Van Migem T, Juuska S, DeConinck P, et al. Prospective evaluation of fetal cardiac function with speckle tracking in healthy fetuses and recipient fetuses with twin-to-twin transfusion syndrome. J Am Soc Echocardiog. 2010; 23:301-308. https://doi.org/10.1016/j.echo.2009.12.024

15. Wohlmuth C, Agarwal1 A, Stevens1 B, et al. Gardiner fetal ventricular strain in uncomplicated and selective growth-restricted monochorionic diamniotic twin pregnancies and cardiovascular response in pre-twin–twin transfusion syndrome. Ultrasound Obstet Gynecol. 2020; 56: 694–704. https://doi.org/10.1002/uog.21911